First Name *

Last Name *

Date of birth *

Phone *

Email *

Please contact me to discuss these services:

Must Check All (If questions please inform clinician) *

I am NOT pregnant or breastfeeding

I have NO known severe allergy to B vitamins, vitamin C, zinc, cobalt, or injection preservatives

I have NO history of severe kidney disease, uncontrolled heart disease, or current fever/infection

I received and understood today’s aftercare instructions

Consent *

I have reviewed the information provided, answered the health questions truthfully, and I voluntarily consent to receive an intramuscular vitamin injection today from D’NuVi Wellness & Hydration, administered by a licensed clinician under medical oversight. I understand the potential risks (injection-site pain/bruising/bleeding, infection, allergy, dizziness/fainting, nerve injury, and rare serious reactions). I understand this is elective wellness care and not a substitute for medical diagnosis or emergency treatment; my questions were answered; I may refuse/stop at any time; and I will seek urgent care/911 for concerning symptoms after my visit. I authorize the creation/storage of my medical record and agree to be contacted for necessary follow-up related to today’s service.

Consent *

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested from D’NuVi. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Consent *

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others from D’NuVi. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Injection Intake & Consent