Consultation

WHAT ARE YOUR GOALS?
Check ALL that apply*
- Energy
- Weight Loss
- Perfomance / Lean
- Help my Deficiency
- Hormone Balance
- Immune Boost
- Skin
- Help with Depression
- General Wellness
- Mood / Focus / Stress
- Inflammation
- Detox
- Other
IS THIS YOUR FIRST HOMEKIT?*
Do you need help deciding which Homekit is best for you?

First Name*
Last Name*
Email*
Enter Email Confirm Email

Which options would you like? - (If physician does not approve, this amount will be fully refunded.)
All Homekits are a 1 month supply.
B12 Homekit (10 doses, 30 day supply)
Price: $189.00
Lipotropic(MIC)/B12 Homekit (10 doses, 30 day supply)
Price: $229.00
Skinny Shot Homekit (10 doses, 30 day supply)
Price: $339.00
Vitamin C Homekit (10 doses, 30 day supply)
Price: $229.00
PowerShot Homekit (10 doses, 30 day supply)
Price: $399.00
Immune Boost Homekit (10 doses, 30 day supply)
Price: $599.00
Glutathione Homekit (10 doses, 30 day supply)
Price: $289.00
L-Carnitine Homekit (10 doses, 30 day supply)
Price: $199.00
B-Complex Homekit (10 doses, 30 day supply)
Price: $229.00
Folic Acid Homekit (10 doses, 30 day supply)
Price: $169.00
B1 (Thiamine) Homekit (10 doses, 30 day supply)
Price: $169.00
B5 (Dexapanthanol) Homekit (10 doses, 30 day supply)
Price: $159.00
Balance Homekit (10 doses, 30 day supply)
Price: $659.00
Skin Bright Homekit (10 doses, 30 day supply)
Price: $478.00
Vitamin D Homekit (10 doses, 30 day supply)
Price: $399.00
NAC (N-Acetylcysteine) HOMEKIT (10 doses, 30 day supply)
Price: $269.00
Choose a Shipping Option:*
- USPS Standard Flat Rate (5-7 Business Days)
- FedEx One Rate (2 Business Days)
- FedEx Overnight (1 Business Day)
- FedEx Priority Overnight
Coupon
NOTES

Add a note (optional)
Total
$0.00
(If physician does not approve, this amount will be fully refunded.)

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 State / Province / Region ZIP / Postal Code Country
Billing Address Same as Shipping Address?*
- Yes
- No
SHIPPING ADDRESS*
Street Address City State ZIP Code
License or Government ID
Max. file size: 50 MB.
If you are unable to upload, please email it to info@vitastir.com

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 understand these injections are to be self injected in the frontal thigh area, as portrayed in the video (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 30 days after opening. I understand , after the 30 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 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
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 Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number 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 info@vitastir.com )
You can choose to make this order a one-time order or plan to get it delivered every month.

Step 1 of 7 - GOALS

WHAT ARE YOUR GOALS?

Which options would you like? - (If physician does not approve, this amount will be fully refunded.)

(If physician does not approve, this amount will be fully refunded.)