Consultation Step 1 of 8 - GOALS 12% 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 Which State do you live in?* 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 We currently do not service the state of Alabama, California, New Hampshire and South Carolina, . We will send you an email when we add these state.* IS THIS YOUR FIRST HOMEKIT?*New PatientRefill OR Existing PatientFirst 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 Which options would you like? - (If physician does not approve, this amount will be fully refunded.)All Homekits are a 1 month supply. Each Homekit must be opened at delivery and refrigerated upon arrival. (In addition to shipping, our current order processing time is 2-5 days)VITASTIR CURRENTLY DOES NOT SHIP TO YOUR STATE - PLEASE CHECK BACK SOONMost Popular:Lipotropic(MIC)/B12 Homekit (10 doses, 30 day supply) Quantity Price: $159.00 Quantity Skinny Shot Homekit (10 doses, 30 day supply) **SALE $289** Quantity Price: $289.00 Quantity Glutathione Homekit (10 doses, 30 day supply) Quantity Price: $159.00 Quantity B12 Homekit (10 doses, 30 day supply) Quantity Price: $119.00 Quantity Fit Shot® Injection HOMEKIT (10 doses, 30 day supply) Quantity Price: $399.00 Quantity GSH High Dose Injection HOMEKIT (15 doses, 30 day supply) Quantity Price: $399.00 Quantity Semaglutide Weight Loss Program1 Month Weight Loss Program W/ Semaglutide Homekit (4 INJECTIONS) - FIRST MONTH DOSAGE ONLY Quantity Price: $899.00 Quantity INCLUDES SEMAGLUTIDE, DIET AND EXERCISE PLAN. PLEASE READ: THIS IS THE FIRST MONTH DOSE ONLY. FOR HIGHER DOSAGES FOR MONTH 2, 3 OR 4, SEE SEMAGLUTIDE OPTIONS BELOW. A minimum BMI of 27 or greater is required to order this medication. This product can be shipped 2-Day or Overnight and does not need to be refrigerated during shipping. As a precaution, please refrigerate once received and opened.1 Month Weight Loss Program W/ Skinny Shot Homekit Quantity Price: $899.00 Quantity 1 Month Weight Loss Program W/ Powershot Homekit Quantity Price: $899.00 Quantity REFRIGERATED PRODUCTSemaglutide Options:A MINIMUM BMI OF 27 OR GREATER IS REQUIRED TO ORDER THIS PRODUCT. 1st MONTH - Semaglutide/B12 Injection Homekit (4 injections, 28 day supply) **SALE** Quantity Price: $145.00 Quantity 2nd MONTH - Semaglutide/B12 Injection Homekit (4 injections, 28 day supply) Quantity Price: $245.00 Quantity 3rd MONTH - Semaglutide/B12 Injection Homekit (4 injections, 28 day supply) Quantity Price: $295.00 Quantity 4th MONTH - Semaglutide/B12 Injection Homekit (4 injections, 28 day supply) Quantity Price: $345.00 Quantity MAINTENANCE DOSE (ongoing) - Semaglutide/B12 Injection Homekit (4 injections, 28 day supply) Quantity Price: $395.00 Quantity Tirzepatide Options:A MINIMUM BMI OF 27 OR GREATER IS REQUIRED TO ORDER THIS PRODUCT. 1st MONTH - Tirzepatide Injection Homekit (4 injections, 28 day supply) **BACK IN STOCK, WILL SHIP TILL 9/10/24, QUANTITIES ARE LIMITED, 1 PER PATIENT ONLY** Quantity2.5mg per week for 4 weeks Price: $199.00 Quantity 2nd MONTH - Tirzepatide Injection Homekit (4 injections, 28 day supply) Quantity5mg per week for 4 weeks Price: $299.00 Quantity 3rd MONTH or MAINTENANCE DOSE- Tirzepatide Injection Homekit (4 injections, 28 day supply) Quantity7.5mg per week for 4 weeks (or ongoing if using as a maintenance dose. This is the most common dose for maintenance.) Price: $399.00 Quantity 4th Month - Tirzepatide Injection Homekit (4 injections, 28 day supply) Quantity10mg per week for 4 weeks Price: $449.00 Quantity 5th Month - Tirzepatide Injection Homekit (4 injections, 28 day supply) Quantity12.5mg per week for 4 weeks Price: $499.00 Quantity 6th Month - Tirzepatide Injection Homekit (4 injections, 28 day supply) Quantity15mg per week for 4 weeks Price: $599.00 Quantity NAD+ Injection Homekit - ACTIVATED FORM (25 doses) Quantity Price: $259.00 Quantity PowerShot Homekit (10 doses, 30 day supply) Quantity Price: $399.00 Quantity Biotin Homekit(10 doses, 30 day supply) Quantity Price: $399.00 Quantity GlyNac (Glycine & NAC) Homekit (10 doses, 30 day supply) Quantity Price: $399.00 Quantity L-Carnitine Homekit (10 doses, 30 day supply) Quantity Price: $199.00 Quantity B-Complex Homekit (10 doses, 30 day supply) Quantity Price: $229.00 Quantity Folic Acid Homekit (10 doses, 30 day supply) Quantity Price: $249.00 Quantity NAC (N-Acetylcysteine) HOMEKIT (10 doses, 30 day supply) Quantity Price: $269.00 Quantity B1/B12 (Thiamine/Cyanocobalamin) Homekit (10 doses, 30 day supply) Quantity Price: $169.00 Quantity B5 (Dexapanthanol) Homekit (10 doses, 30 day supply) Quantity Price: $159.00 Quantity Balance Homekit (10 doses, 30 day supply) (REG $659, SALE $499) Quantity Price: $499.00 Quantity Vitamin C Homekit (10 doses, 30 day supply) Quantity Price: $229.00 Quantity Immune Boost Homekit (10 doses, 30 day supply)**SALE** Quantity Price: $399.00 Quantity Skin Bright Homekit (10 doses, 30 day supply) **SALE** Quantity Price: $349.00 Quantity Vitamin D Homekit (10 doses, 30 day supply) Quantity Price: $399.00 Quantity Bremelanotide Homekit (8 doses, 30 day supply) Quantity Price: $599.00 Quantity Choose a Shipping Option:* Free Shipping (Pharmacy processing time 5-14 days) FedEx Overnight (Ships M-Th) FedEx Priority Overnight (Ships M-F and Saturday Delivery) Coupon (Not Valid for SALE products) NOTES Add a note (optional)Total $0.00 (If physician does not approve, this amount will be fully refunded.) 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 applyHiddenDo 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 I understand that if I am taking anti-coagulants (blood thinners) then I may have delayed clotting when giving myself an injection. I understand that in this circumstance I may bleed a little more then the usual patient. If I have any questions about this I will discuss with my nurse at [email protected].* I understand and I AGREE 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.* 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] REQUIRED "HOW TO" VIDEO* I have watched the video and know how to give myself an injection www.vitastir.com/howtoinject (VIDEO AVAILABLE HERE)I WILL FOLLOW THE INSTRUCTIONS AND DOSAGE AMOUNTS ON MY BOTTLE. I understand these injections are to be self injected in the area written on my bottle. I will watch the video to learn how to self-inject. I am aware the instructional video is available to watch at www.vitastir.com/howtoinject. I agree I will use the syringes and vitamins as directed.* I Agree I understand that my custom package is ordered for me. My vial or package I start at VITAstir will have an expiration date that is 28 days after opening. I understand, after the 28 day period, medications are considered expired and should be discarded by me.* I Agree CONSENT FORM: I acknowledge that I have received instructions and educational material from VITAstir for the administration of home injections. 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 understand that if I elect to do self-administered injections or if another designated individual gives me the injection, I should be attended for at least 30 minutes by a responsible adult to assist me in case of a severe reaction. - I agree to have on hand an epinephrine injector to use in case of a systemic reaction. I acknowledge that I have received instruction on its use and administration. I further understand that I must identify that the date of this medication is current. If not, I will call for a renewal of my medication. - 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, self-injection procedures or injuries in conjunction with the injection therapies. I also understand that I am able to use VITAstir services and go to any pharmacy of my choosing.* I AGREE I UNDERSTAND THIS IS A NON-REFUNDABLE PRODUCT AND CANNOT BE RETURNED. I AGREE TO THE REFUND POLICY AVAILABLE AT www.vitastir.com/refund-policy/ - I authorize VITAstir to charge my credit card for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.* I Agree I agree to give my consent to treat. I have read the Telehealth Consent located at www.vitastir.com/consent* 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):* (If physician does not approve, this amount will be fully refunded.)Total $0.00 (If physician does not approve, this amount will be fully refunded.)Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name ONE-TIME OR SUBSCRIPTION ORDER?* ONE-TIME ORDER ONLY RECURRING SUBSCRIPTION MONTHLY (Subscription will be charged on this day every month. Cancel anytime before next billing by emailing [email protected] ) You can choose to make this order a one-time order or plan to get it delivered every month. (If you are choosing to have recurring orders of Semaglutide, you are agreeing to a tiered dosing schedule.)***IMPORTANT*** YOU ARE AGREEING TO A SUBSCRIPTION PROGRAM* I AGREE TO A MONTHLY SHIPMENT AND AUTOMATIC BILLING TO MY CREDIT CARD ON THIS DAY EVERY MONTH (IF YOU DO NOT WANT THIS OPTION, CLICK "ONE TIME ORDER' IN THE PREVIOUS QUESTION)OFFERS***SPECIAL OFFER*** Would you like to add High-Dose B12 to this order for only $99 Quantity Price: $99.00 Quantity B12 (1000mcg/ml) Homekit (10 doses, 30 day supply)(reg $189) Δ
