Auto Approval Process Acknowledgement


Indication for Use

You are requesting treatment with one or more lifestyle-enhancement therapies including MIC+B12 injections, Vitamin B12 (cobalamin), Glutathione, NAD+ (Nicotinamide Adenine Dinucleotide), and/or Metformin to support metabolism, enhance energy production, promote cellular health, and potentially provide anti-aging benefits. These therapies are not intended for treatment of any specific medical condition.

Purpose of This Consent

This form ensures you understand:

  • The reason for prescribing these products

  • Their potential benefits and risks

  • The off-label status of certain components

  • The monitoring and follow-up plan

  • Your responsibilities during treatment

Background Information

  • MIC+B12 combines lipotropic agents (Methionine, Inositol, Choline) with Vitamin B12 to aid fat metabolism and boost energy.

  • Vitamin B12 (cobalamin) is essential for red blood cell production, neurological function, and DNA synthesis. Deficiency can arise from dietary insufficiency (e.g., vegan diets), malabsorption, or interactions with medications such as Metformin or proton-pump inhibitors.

  • Glutathione is a natural antioxidant that reduces oxidative stress, supports detoxification, and enhances immune function.

  • NAD+ is a coenzyme vital for mitochondrial energy production, DNA repair, and overall cellular health.

  • Metformin is a prescription medication for type 2 diabetes that is being studied off-label for metabolic and anti-aging effects.

Off-Label Use Notice

Glutathione, NAD+, and Metformin are not FDA-approved for wellness or anti-aging indications. Their use in this program is off-label, intended solely for health optimization and lifestyle enhancement.

Potential Benefits

  • MIC+B12: Enhanced metabolism and fat burning

  • Vitamin B12: Improved energy, neurological health, and cognitive function

  • NAD+: Increased cellular energy and mitochondrial function

  • Glutathione: Detoxification and antioxidant protection

  • Metformin: Improved insulin sensitivity and metabolic efficiency

  • All therapies: Increased vitality, reduced fatigue, and potential anti-aging effects

Potential Risks and Side Effects

MIC+B12

  • Common: Injection-site redness, swelling, pain; nausea; mild diarrhea

  • Serious: Allergic reaction (rash, itching, breathing difficulty); elevated liver enzymes; rare injection-site infection

Vitamin B12

  • Common: Mild diarrhea; skin rash or itching; headache; nausea

  • Rare: Severe allergic reactions (anaphylaxis); hypokalemia with rapid correction; exacerbation of acne or rosacea

Glutathione

  • Common: GI discomfort; headache; skin reactions (rash, itching)

  • Rare: Allergic reaction; localized skin lightening

NAD+

  • Common: Nausea; fatigue; flushing; headache; abdominal cramping; dizziness

  • Less common: Anxiety; sweating; muscle cramps; injection-site pain or swelling

Metformin

  • Common: GI upset (nausea, bloating, diarrhea)

  • Rare but serious: Lactic acidosis (especially with kidney or liver impairment); long-term vitamin B12 deficiency

Risks and Considerations

  • Allergic Reactions: Discontinue treatment and seek immediate care if you experience rash, swelling, or breathing difficulty.

  • Kidney Function: Use Metformin cautiously with impaired kidney function.

  • Supplement Interactions: Disclose all medications and supplements to avoid interactions, particularly those affecting absorption of Vitamin B12.

Monitoring and Follow-Up

  • Attend all scheduled follow-up visits for assessment of therapy response and side-effect monitoring.

Patient Responsibilities

By consenting to these therapies, you agree to:

  • Follow the prescribed treatment plan exactly

  • Report new or worsening symptoms promptly

  • Avoid altering dosage or frequency without medical approval

  • Attend all recommended follow-up appointments

  • Inform your provider of any changes in medications, supplements, or health status

Patient Acknowledgment and Consent

  • I have read and understood the information provided in this consent form.

  • I understand the potential risks and benefits of using this product and the off-label nature of this treatment.

  • I agree to adhere to the monitoring plan and to inform my healthcare provider of any side effects or concerns.

By checking the consent box, I voluntarily consent to the use of this product for the treatment of my symptoms.