Consultation – Resubmit Information Step 1 of 7 - GOALS 14% 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?*New PatientRefill OR Existing PatientDo you need help deciding which Homekit is best for you?I know what I wantI need help deciding, have a nurse call me (this option may cause delays as an extra consult is being requested) 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) Quantity Price: $164.00 Quantity Lipotropic(MIC)/B12 Homekit (10 doses, 30 day supply) Quantity Price: $199.00 Quantity Skinny Shot Homekit (10 doses, 30 day supply) Quantity Price: $339.00 Quantity Vitamin C Homekit (10 doses, 30 day supply) Quantity Price: $229.00 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 NAD+ Homekit (10 doses, 30 day supply) Quantity Price: $799.00 Quantity Immune Boost Homekit (10 doses, 30 day supply) THIS IS A COLD PRODUCT, IT REQUIRES OVERNIGHT SHIPPING Quantity Price: $599.00 Quantity Glutathione Homekit (10 doses, 30 day supply) THIS IS A COLD PRODUCT, IT REQUIRES OVERNIGHT SHIPPING Quantity Price: $249.00 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: $149.00 Quantity B1 (Thiamine) Homekit (10 doses, 30 day supply) Quantity Price: $149.00 Quantity B5 (Dexapanthanol) Homekit (10 doses, 30 day supply) Quantity Price: $139.00 Quantity Balance Homekit (10 doses, 30 day supply) THIS IS A COLD PRODUCT, IT REQUIRES OVERNIGHT SHIPPING Quantity Price: $659.00 Quantity Skin Bright Homekit (10 doses, 30 day supply) THIS IS A COLD PRODUCT, IT REQUIRES OVERNIGHT SHIPPING Quantity Price: $478.00 Quantity Vitamin D Homekit (10 doses, 30 day supply) THIS IS A COLD PRODUCT, IT REQUIRES OVERNIGHT SHIPPING Quantity Price: $399.00 Quantity Choose a Shipping Option:* USPS Standard Flat Rate (5-7 Days, M-F) Fedex One Rate (2 Days, M-F) (FREE SHIPPING SALE) Fedex Standard Overnight (M-F) Fedex Priority Overnight (M-F) Coupon NOTESAdd 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?* 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 applyAre 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country 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 ID - REQUIRED*Max. file size: 256 MB. 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):* Total $0.00 (If physician does not approve, this amount will be fully refunded.)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. Δ
