Lipo / Vitamin B12 Injection Intake Form Template
Lipotropic (Lipo) and Vitamin B12 injections are commonly used in wellness and medical weight management programs to support energy metabolism, fat mobilization, and cognitive function. This intake form captures the patient relevant symptoms and screens for contraindications including Leber's disease, cobalt allergy, and nutritional deficiencies before initiating therapy.
Free Template
Lipo / Vitamin B12 Intake Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Lipo / Vitamin B12 Intake Form
1 General Patient Information
Please provide your personal information.
General Patient Information
Please provide your personal information.
First Name
Jane
Last Name
Smith
Date of Birth
—
Can you confirm you are 18 years or older?
Height
e.g. 5'8"
Weight
e.g. 170 lbs
2 Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Are you actively taking any medications? If so, please list them.
List all current medications, dosages, and frequencies
Do you have any medication allergies? If so, please list them.
List all known drug allergies and reactions
Are you currently being treated or have you been treated for any medical conditions? If so, please list them.
List all current and past medical conditions
Have you had any past surgeries? If so, please list them.
List all surgeries and approximate dates
What is/was your sex assigned at birth?
Male
Emergency contact name and phone number
Name — (555) 000-0000
Mailing address
123 Main St, City, State, ZIP
Any other questions or concerns?
Optional — share anything else you'd like your provider to know
3 Symptoms
Select all symptoms that currently apply to you.
Symptoms
Select all symptoms that currently apply to you.
4 Contraindications
Select all conditions that currently apply to you.
Contraindications
Select all conditions that currently apply to you.
Preview only. Your live form will include your branding and e-signature capture.
Compliance & Regulatory Notes
Review these notes before deploying this form in your practice.
Vitamin B12 injections (cyanocobalamin, methylcobalamin) are available by prescription and through compounding pharmacies. Verify pharmacy licensure before dispensing. See FDA: https://www.fda.gov/drugs/human-drug-compounding
Leber's disease (hereditary optic neuropathy) is a contraindication for cyanocobalamin-based B12 due to risk of optic atrophy. Methylcobalamin may be considered as an alternative with specialist guidance.
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- Branded intake on your website
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Free 30-minute walkthrough
Sources & References
Frequently Asked Questions
What is in a Lipo/B12 injection?
Lipo/B12 injections typically contain a combination of lipotropic compounds (methionine, inositol, choline) and Vitamin B12 (methylcobalamin or cyanocobalamin). The exact formulation varies by compounding pharmacy.
How often are Lipo/B12 injections given?
Frequency varies by protocol, but weekly injections are common. Your provider will determine the appropriate frequency based on your health goals and response to therapy.