NAME *

First Name

Last Name

HAVE YOU HAD B12 SHOTS BEFORE? *

YES

NO

DO YOU CURRENTLY SELF-INJECT OR HAVE YOU PREVIOUSLY? *

YES

NO

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.

I AGREE

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.

I AGREE

SUBSCRIBE TO OUR NEWSLETTER

By checking this box I agree to be contacted by Dr Ayanna Knight Ltd. with information regarding any news or discounts being offered by the clinic. Your information will not be shared with any third party or other organisation.

I AGREE