Client Information

First name*

Last name*

Email*

Phone*

Date of Birth*

Year

Month

Day

Treatment Overview

You are electing to receive a complimentary Vitamin B12 and/or NAD+ injection administered by a licensed medical provider at The Beauty Standard.

These injections are designed to support energy, metabolism, cellular function, and overall wellness. While they are generally safe, any injection carries a small risk of reaction, bruising, or discomfort at the injection site.

Medical Screening Questions

Are you currently pregnant or breastfeeding?*

Yes

Do you have a known allergy to cobalamin (B12), cobalt, or preservatives?*

Yes

Have you ever had a reaction to a vitamin injection?*

Yes

Are you taking any blood thinners or anticoagulants?*

Yes

Do you have any chronic health conditions (e.g. kidney disease, liver disease)?*

Yes

Are you currently under the care of a physician for any medical condition?*

Yes

If you answered “Yes” to any of the above, please consult with our medical team before proceeding.

Consent & Acknowledgement

By signing below, I acknowledge and agree to the following:

I have voluntarily elected to receive a B12 and/or NAD+ intramuscular injection.
I have disclosed any relevant medical history to the best of my knowledge.
I understand the possible side effects, including but not limited to: injection site discomfort, bruising, mild headache, or rare allergic reaction.
I understand that results vary and are not guaranteed.
I release The Beauty Standard and its staff from liability for any complications or outcomes resulting from this free wellness treatment.