Consultation - Resubmit Information

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

WHY ARE YOU RESUMMITING YOUR FORM?

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 apply
Hidden
Do 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 apply
Do 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 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 [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 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):*

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.
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Consultation – Resubmit Information