Existing Patient Form - Home Kits

Name*

First and Last Name

Are you a New Patient or Existing Patient?*

STOP YOU ARE FILLING OUT THE WRONG FORM

This form is for existing patients that have ordered previously and received an online physicians consultation. You can find the New Patient Home Kits Form at www.vitastir.com/new-patient-form-homekits

Email*

Phone Number*

Have your allergies, medical history, medications or supplements changed?*

Yes
No

Allergies*

Past Medical 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
Pre/Peri/Post Menopause
None

Check ALL that apply

Are you pregnant or breast feeding?*

Yes
No
I'm a male

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

Prescription medications you are currently taking:*

Non-Prescription medications, vitamins or supplements you are currently taking:*

Do you drink alcohol?*

Yes
No

Alcohol consumption is not recommended on the same day that you administer an injection. In the case that this occurs, the side effect is nausea.*

I Understand

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

We would like to make sure each patient is educated about the process of giving themselves an intramuscular injection. Please watch the video at the bottom of the page. You can also find this instructional video at www.vitastir.com/howtoinject*

I have watched the required video below, "HOW TO GIVE YOURSELF AN INTRAMUSCULAR INJECTION" . I understand this video is also available at www.vitastir.com/howtoinject

CONSENT FORM: I acknowledge that I have received instructions and educational material from VITAstir Clinic, PC 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 Clinic, PC as needed. By signing this form, I assume full responsibility for receiving my injections and release VITAstir Clinic, PC from any liability or responsibility for any reactions, conditions or self-injection procedures in conjunction with the injection therapies.*

I AGREE

SIGNATURE. I HAVE READ THE ABOVE CONSENT FORM (First and Last Name)*

Date (mm/dd/yyyy):*

Existing Patient Form Home Kits