Request a Doctor

Name*

First and Last Name

Email*

Phone Number*

Reason For Consultation?*

(Please list all symptoms you are currently experiencing.)

When do you need care?*

(If you need care immediately please give us a call right after filling out this form.) (If this is an emergency please call 911)

Preferred Pharmacy Name*

(This is where your medication will be called in)

Preferred Pharmacy Phone Number*

Preferred Pharmacy Address

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Do you have health insurance? (Not required)*

Yes
No

Reason for visit? Please describe all symptoms in detail.*

How did you hear about us?*

Race*

Sex*

Male
Female

Marital Status*

Single
Married
Divorced
Widowed

Occupation*

Allergies*

Past Medical History*

Please fill out as completely as possible.

Who is you primary care physician?*

Name and Address of Pharmacy where you would like your medication called into?*

Phone Number of Pharmacy?*

Do you have any of the following conditions?*

Fibromyalgia
Chronic Fatigue Syndrome
Liver or Kidney problems
Heart Problems
High Blood Pressure
Thyroid Issues
Hormone Issues
Pre/Peri/Post Menopause
None

Check ALL that apply

Are you pregnant or breast feeding?*

Yes
No
I'm a male

Past surgical history:*

Prescription medications you are currently taking:*

Non-Prescription medications, vitamins or supplements you are currently taking:*

Do you drink alcohol?*

Regularly
Socially
Never

What is your weekly exercise and activity level?*

I am an Olympic Athlete
Exercise frequently
Rarely
Never

On a scale of 1-10, What is your pain level? (10 being extreme pain):*

SIGNATURE. I HAVE READ THE CONSENT TO TREATMENT BELOW. (First and Last Name)*

Consent to Treatment and other Acknowledgements: By reading and signing this document, I, the undersigned patient (or authorized representative) consent to and authorize the performance of any treatments by Vitastir Clinic, PC Staff including injections, infusions, examinations, medications, anesthesia, medical services, and surgical or diagnostic procedures (including but not limited to the use of lab and radiographic studies) as ordered or approved by my attending physician(s), or any healthcare professional assigned to my care by my attending physician(s), and I acknowledge and consent to the following: During the course of my care and treatment, I understand that various types of examinations, tests, diagnostic or treatment procedures (“procedures”) may be necessary. These procedures may be performed by physician(s), nurses, technicians, physician assistants, or other healthcare professionals. While routinely performed without incident, there may be material risks associated with these procedures. If I have any questions concerning these procedures, I will ask my physician(s) to provide me with additional information. I also understand my physician may ask me to sign additional Informed Consent documents relating to specific procedures. Anytime an injection is given, there is potential for pain, bruising, or swelling at the injection site. These reactions are fairly mild and self-limited and usually resolve within 24-48 hours. Rare allergic reactions to the injection or infusion may occur. It is important that you inform the health care professional or proceed to the nearest emergency room if you experience severe side effects such as difficulty breathing, lips swelling, hives and chest pain. Physicians and healthcare professionals cannot guarantee any specific result(s) of any examination, treatment, procedure or medical care. I release the Vitastir Health staff, its physicians and healthcare professionals from any liability for any accident or injury that is not directly caused by the negligence of Vitastir Clinic, PC Staff or its employees.I understand that the healthcare professionals involved in my care will rely on my documented medical history, as well as other information provided by me, my immediate family, or others having information about me, in determining whether to perform or recommend procedures. I agree that I have provided accurate and thorough information regarding my medical history and any conditions or events which may impact medical decision-making. In return for services to be provided by Vitastir Clinic, PC , I agree to pay for services rendered by Vitastir Clinic, PC Staff to me or for my benefit. I agree to pay in full for such services at the time the services are received. By signing this document, I certify that I have read and understand its contents and that information provided by me is accurate and any questions I had have been answered to my satisfaction. I believe I have adequate information and knowledge upon which to base an informed consent to the proposed procedure (Injection/Infusion). I am aware of the potential risks involved as outlined.

Date (mm/dd/yyyy):*

I understand someone will call me within 24 hours to set up my chart and discuss my conditions. If this is an emergency, I will call 911. (If you cannot wait, please call us immediately after filling out this form.)*

I agree

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