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ORDER B12 SELF-INJECTION KIT

STEP 2:

Complete our Medical Declaration Form. Your medical history & health needs are reviewed by Dr Ayanna Knight prior to completing your order

B12 SELF-INJECTION MEDICAL DECLARATION FORM


NAME *
NAME
WHICH B12 SELF-INJECTION KIT DO YOU REQUIRE? *
DELIVERY DETAILS
NAME *
NAME
ADDRESS *
ADDRESS
YOUR HEALTH & WELLBEING NEEDS
HAVE YOU HAD B12 SHOTS BEFORE? *
DO YOU CURRENTLY SELF-INJECT OR HAVE YOU PREVIOUSLY? *
MEDICAL DECLARATIONS
MEDICAL DECLARATION 1 *
By checking this box I confirm that ALL of the information I have given on this order form constitutes full disclosure of my health and medical conditions.
MEDICAL DECLARATION 2 *
By checking this box I confirm that I have read the written instructions regarding the B12 Self-Injection Kit. I confirm that I understand the self-injection technique and I feel confident in carrying out this procedure. I understand that if I have any questions, queries or concerns regarding any aspect of the self-injection procedure I must contact Dr Ayanna Knight - Cosmetic Skin Care, Health & Wellbeing Clinic prior to using this service.

If you would prefer to book an in clinic consultation with Dr Ayanna Knight for B12 Methylcobalamin Self-Injection Kit, please click the button below


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