Other side effects may be experienced by people who have an allergy or sensitivity to cobalamin and cobalt. If this is the case, then it is advisable to avoid vitamin B12 supplementation altogether and instead seek to eat the foods that contain naturally occurring B12. In addition, B12 should be avoided by people suffering from Leber's disease, a hereditary disease in which the optic nerve wastes away. Ingesting vitamin B12 can actually speed up the atrophy of the optic nerve resulting in rapid loss of central vision. Also, there is always a risk of fainting or infection with any skin puncture. A multitude of conditions can be caused by Vitamin B-12 Deficiency including:

***B12 Deficiency can mimic Alzheimer's disease, multiple sclerosis, early Parkinson's Disease, infertility in women and Chronic Fatigue Syndrome. Therefore,more problems than not arise from B12 deficiency than they do from ingestion of the vitamin itself.

By signing this form and on behalf of myself, my heirs, executors, administrators and assignees, I agree to hereby release, forever discharge and hold harmless the entity doing business as Health and Aesthetics and the respective owners, officers, directors, employees, agents, representatives, governing bodies, advising committees, and subcontractors of the entity doing business as Health and Aesthetics as well as the company and/or companies sponsoring this event and their agents, representatives, employees, successors, and assignees from any and all liability, claims, demands, actions, causes of action, injury or damage which may result from receiving a B-12 shot administered by the entity doing business as Health and Aesthetics. p>

I understand that Health and Aesthetics makes no claim or guarantee that I will experience any benefit from B-12. Health and Aesthetics does not guarantee results. I understand that individual results will vary.

I have been made aware that Health and Aesthetics is not an insurance provider for Medicare or any private insurance company. Therefore, I understand that Health and Aesthetics will not bill my health insurance for this procedure.

I acknowledge that I have read the purpose of B-12 metabolically, what B-12 is medically indicated for and any contraindications, side effects or risk(s) associated with receiving B-12. I have also had the opportunity to ask any questions about Vitamin B-12 shots and Vitamin B-12.

I have read this form and understand and comprehend its contents. After reading and understanding the benefits and risks of ingesting B-12 and the contents of this form in its entirety, I consent to receive a B-12 shot or B-12 shots from the entity doing business as Health and Aesthetics now and in the future. I also understand that if I am a female and become pregnant or start breast-feeding in the future, it is my responsibility to make Health and Aesthetics aware of the change in status. I further realize that I can not receive any B-12 shots if I am pregnant or breastfeeding. I understand that the confidentiality of this information will be maintained within legal limits.