Consultation – Update Medical Information "*" indicates required fields Step 1 of 8 - GOALS 12% WHAT ARE YOUR CURRENT 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 First Name*PLEASE USE YOUR LEGAL FIRST NAME ONLY. ANY OTHER NICK NAMES OR VARIANCES WILL CAUSE DELAYS IN YOUR ORDER. Last Name*PLEASE USE YOUR LEGAL LAST NAME ONLY. ANY OTHER NICK NAMES OR VARIANCES WILL CAUSE DELAYS IN YOUR ORDER. What 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 Height (feet)*Please enter a number from 1 to 9.Please enter just the feet, and then in the next field enter in inches. So if you are 5'11, please enter in 5 this field and 11 in the next field.And Inches*Please enter a number from 0 to 11.Weight (lbs)*Please enter a number from 75 to 1200.BMINOTESAdd a note (optional) Date of Birth*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?* 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 Select AllCheck ALL that applyThis field is hidden when viewing the formDo you have any of the following conditions? Pancreatitis or history of pancreatitis Medullary thyroid cancer or family history of medullary thyroid cancer Diabetic retinopathy or Diabetes Type 1 Renal impairment NONE Select AllCheck 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 Have you previously taken a GLP before such as Semaglutide, Tirzepatide, Ozempic, Wegovy, Mounjaro etc.?* Yes No Which GLP have you previously taken? And what was the dosage of your injection? Has there been a gap in your treatment? PLEASE GIVE THE DOCTOR AS MANY DETAILS AS POSSIBLE HERE FOR FASTER APPROVAL.*Do you have any of the following conditions?* High Blood Pressure High Cholesterol High Blood Sugar NONE Do you have any of the following? SELECT ALL THAT APPLY* High Waist Circumference Sleep Apnea Food Addiction Family History of Obesity None 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 I understand that my medication is prepared in a compounding pharmacy in accordance with Section 503A of the Federal Food, Drug, and Cosmetic Act and is dispensed solely pursuant to a valid patient-specific prescription from a licensed healthcare provider. If I am ordering Tirzepatide, I undertand the following: This compounded medication contains Tirzepatide combined with glycine and vitamin B12, and is formulated specifically for individual patients who may not tolerate standard formulations or who require a customized therapeutic approach. It is prepared in accordance with Section 503A of the Federal Food, Drug, and Cosmetic Act and is dispensed solely pursuant to a valid patient-specific prescription from a licensed healthcare provider. Our compounded formulation is not affiliated with, endorsed by, or intended to replace the FDA-approved product manufactured by Eli Lilly. The addition of glycine and vitamin B12 is intended to support patients experiencing issues such as fatigue, muscle loss, or neuropathy—common concerns during weight loss or diabetes treatment—and may offer metabolic, neurological, and musculoskeletal benefits. This medication is not made for resale, bulk distribution, or office use, and is compounded exclusively to meet the clinical needs of individual patients when commercially available alternatives are not appropriate.* 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 NO RETURNS - 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):* Δ
