CONSULTATION IN CLINIC FORM Step 1 of 5 - GOALS 20% WHAT ARE YOUR GOALS?Check ALL that apply* Energy Weight Loss Perfomance / Lean Help my Deficiency Hormone Balance / Fertility / PCOS Immune Boost Skin Help with Depression General Wellness Mood / Focus / Stress Inflammation Detox Other Email* Enter Email Confirm Email IS THIS YOUR FIRST VISIT?*New PatientRefill OR Existing PatientWHICH TREATMENT ARE YOU INTERESTED IN?*First Name*Last Name*I agree to receive VITAstir® discount codes and promotional emails, and this agreement isn’t a condition of purchase. I also agree to Privacy Policy and Terms and Conditions.* I Agree Date of Birth*Height*Feet and Inches (Example: 5' 1")Weight (lbs)*Race*(We ask this because some populations are more susceptible to certain conditions than others.)Sex* Male Female Allergies*Any new allergies?*What is your occupation?*Past Medical and Surgical History*Please fill out as completely as possible.Do you have any of the following conditions?* Select All Fibromyalgia Chronic Fatigue Syndrome Liver or Kidney problems Heart Problems High Blood Pressure Thyroid Issues Hormone Issues Blood Clots Pre/Peri/Post Menopause Cancer Stroke or Seizure None Check ALL that applyThis field is hidden when viewing the formDo you have any of the following conditions? Select All Pancreatitis or history of pancreatitis Medullary thyroid cancer or family history of medullary thyroid cancer Diabetic retinopathy or Diabetes Type 1 Renal impairment NONE Check ALL that applyDo you have pancreatitis or a history of pancreatitis?* Yes No Do you have medullary thyroid cancer or a history of medullary thyroid cancer?* Yes No Do you have renal (kidney) impairment?* Yes No Do you have type 1 diabetes or diabetic retinopathy?* Yes No Are you taking any blood thinners?* Yes No Are you pregnant or breast feeding?* Yes No Prescription Medications OR Non-Prescription Supplements you are currently taking:*Do you have any new prescription Medications OR Non-Prescription Supplements you are currently taking?*Do you drink alcohol?* Yes No It is not recommended that you consume alcohol on the same day of your injection or IV therapy.* I Understand Phone Number*This is the Phone Number the Doctor will use to call you, if necessary. Please double check to make sure that it is correct.BILLING ADDRESS* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Billing Address Same as Shipping Address? Yes No SHIPPING ADDRESS* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code License or Government IDMax. file size: 256 MB.If you are unable to upload, please email it to [email protected] CONSENT FORM: I acknowledge that I have received instructions and educational material from VITAstir Injections & IV's. I acknowledge that the risks of injections has been discussed with me. I understand that these risks include, but are not limited to, local reactions, rashes, bruises, etc. I agree to have on hand an epinephrine injector to use in case of a systemic reaction. I understand that it is my responsibility to maintain follow up appointments with my physician at VITAstir as needed. By signing this form, I assume full responsibility for receiving my injections and release VITAstir and its physicians from any liability or responsibility for any reactions, conditions, injuries in conjunction with the injection therapies.* I AGREE I agree to VITAstirs Terms and Conditions. I have read the Terms and conditions located at https://www.vitastir.com/terms-and-conditions/* I Agree PRINT NAME. I HAVE READ THE ABOVE CONSENT FORM AND AGREE TO E-SIGN. (First and Last Name)*SIGNATURE*Date SIGNED (mm/dd/yyyy):* Δ
