Official Vitamin B12 Medical Consent Form

For the request of Intramuscular Hydroxocobalamin B12 Injection please state any of the following health conditions that apply to you. If you have symptoms of ill health not listed below please indicate “other and state them in the space provided. (Please include other symptoms that may affect your sense of wellbeing such as; poor sleep, tiredness, fatigue & low mood etc)

If you would prefer a face-to-face video call to discuss with us if this would benefit you then please click the button below.

Otherwise please fill in the Medical consent form below and we will be in touch as soon as possible.

You don’t have permission to this Form.

B12 Face-to-Face booking

Fill in the form below and we will be in touch to discuss a suitable time for a video call.

How can we help?


  • We Are Wellbeing Ltd
  • Romero House
  • Airport West
  • Yeadon
  • Leeds
  • West Yorkshire
  • LS19 7ZA