+44 1384 638554
[email protected]
249 Halesowen Rd, Cradley Heath
Vitamin B12 Eligibility Check
Before booking your Vitamin B12 injection, please answer a few quick questions to ensure this service is safe for you.
Are you aged 18 or over?
*
Yes
No
First Name
*
Last Name
*
Date of birth
*
Postal Code
*
Lifestyle and diet details
Your reason(s) for requesting a b12 injection. You may select more than one option:
*
I follow a vegan/vegetarian diet and need a reliable source of B12
I want to try to reduce the feeling of tiredness and fatigue
I want to try to improve my mental focus and clarity
To achieve optimal B12 levels for a healthy body
Which category does your regular diet fall under?
*
Vegan
Vegetarian
Carnivore
Ketogenic
Vegetarian diet with consumption of eggs and seafood
Plant-based diet with a moderate amount of meat consumption
Other
How frequently do you consume animal-based foods such as meat, fish and egg products?
*
Never
Once a month
Once every 2 weeks
Once a week
Twice a week
Once a day
How frequently do you consume dairy products such as milk and cheese?
*
Never
Once a month
Once every 2 weeks
Once a week
Twice a week
Once a day
Do you take any of the following supplements?
*
Vitamin A
Vitamin C
Vitamin D
Vitamin E
Vitamin K
Folic Acid
Multivitamin
Vitamin B12
Iron
Zinc
None
Medical History
Please accurately complete the following consultation form to enable our medical team to check that the B12 injection is clinically suitable and safe for you. If you are identified as someone for whom this service is not suitable, please get in touch with your GP as they will be in a better position to manage your B12 levels.
Have you ever had a bad reaction to an injection?
*
Yes
No
Are you allergic to Hydroxocobalamin or Cobalt?
*
Yes
No
Are you or could you be pregnant/breastfeeding? Not needed unless confirmed by blood test/diagnosis
*
Yes
No
Have you had a B12 injection in the last 28 days from your GP or any other clinic/provider?
*
Yes
No
Are you due to receive a B12 injection from your GP or any other clinic/provider in the next 28 days?
*
Yes
No
Have you ever suffered from any heart problems/diseases such as heart attack, angina, irregular heart rhythm, ischaemic heart disease, congestive heart failure, heart palpitations, valvular heart disease or stroke? E need blood test
*
Yes
No
Have you ever suffered from peripheral vascular disease (atherosclerosis) or had a stent put in?
*
Yes
No
Have you ever been prescribed any medication by your doctor to correct your potassium levels?
*
Yes
No
Are you taking any medication prescribed or over the counter? C
*
Yes
No
Do you suffer from any kind of liver or kidney disease or impairment? if severe
*
Yes
No
Have you suffered or currently you suffer from any kind of cancer? need blood test
*
Yes
No
Do you currently take any medication that weakens your immune system?
*
Yes
No
Have you ever been diagnosed with Lebers Hereditary optic neuropathy?
*
Yes
No
Do you suffer from any abnormality/impairment in absorption of food nutrients across the digestive system whether single or multiple nutrients (malabsorption syndrome?
*
Yes
No