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Product Intake Form
Personalized Protocol for Product Name
Complete this brief assessment to ensure your treatment is safe, effective, and tailored to your goals.
Which B12 MIC⁺ benefits are you most interested in?
Select up to 3 options that best match your goals.
Selected: 0/3
Boost energy and focus
Support metabolism and fat utilization
Improve mood and motivation
Enhance liver detox and fat metabolism
Support immune and cardiovascular health
Healthier skin, hair, and nails
Support weight management and performance
Overall wellness and resilience
Do any of the following apply to you?
Selected: 0/1
None
Allergy to B12, cobalt, sulfur, l carnitine, methionine, inositol, choline, or any component of the injection
Severe uncontrolled anxiety or panic disorder
Severe liver disease or kidney disease stage 4 or higher
Do any of the following apply to you?
Selected: 0/1
None
Mild liver enzyme elevation or fatty-liver disease
Chronic anemia of unknown cause
Long-term use of metformin or proton-pump inhibitors
Do any of the following apply to you?
Selected: 0/1
None
Controlled hypertension
Alcohol overuse or history of fatty liver
Occasional chest tightness, palpitations, dizziness, or prior arrhythmias (stable)
Are you willing to possibly experience side effects with this medication, such as flushing or injection-site soreness?
See website and prescribing info for full list.
Yes
No, decline treatment
Do you agree to inform your other healthcare providers that you are starting B12 MIC⁺ and continue routine care with them?
Yes
No, decline treatment
Safety Check
Please review the following.
YOU'RE ALMOST DONE
You're one step away from completing your intake form but we still need your other products medical intake forms.
What happens next:
- Your responses will be securely stored
- You'll be redirected to complete additional product forms
Final Step
COMPLETE SUBMISSION
Thank you for completing your medical intake form, to finish the process please click the submit button.
Your submission is secure and encrypted
- Your provider will review your medical information within 24 hours
- You'll receive an email confirmation shortly
- Questions? Contact support anytime
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