New Patient Form (Home Kits) - VITAstir Clinic

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New Patient Form (Home Kits)

THIS FORM IS FOR PATIENTS WHO HAVE PURCHASED A HOMEKIT.

Please purchase a HOMEKIT before filling out this form. After filling out this medical history form a chart can be created for you. This chart will be given to the Physician. The Physician will contact you within 24-48 hours.

First and Last Name*
First and Last Name
Are you a New Patient or Existing Patient? (For HomeKits)*
STOP - YOU ARE FILING OUT THE WRONG FORM
Please go to https://www.vitastir.com/existing-patient-form-homekits/
Have you placed an order for a Homekit?*
STOP - THIS FORM IS ONLY FOR THOSE WHO HAVE PLACED AN ORDER FOR A HOMEKIT.
Please go to https://www.vitastir.com/b12shots to place an order first.
Email*
Phone Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you have health insurance?*
- Yes
- No
Date of Birth*
Height*
Feet and Inches (Example: 5' 1")
Weight (lbs)*
Race*
Sex*
- Male
- Female
Allergies*
What is the reason for your consultation?*
What is your occupation?*
Past Medical History*
Please fill out as completely as possible.
Who is you primary care physician?*
(In case of emergency)
Address of primary care physician?*
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 apply
Have you recently stopped or started smoking?*
- Yes
- No
- I've never smoked
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
- I'm a male
Past surgical history:*
Prescription medications you are currently taking:*
Non-Prescription medications, vitamins or 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
How did you hear about us?*
REQUIRED "HOW TO" VIDEO*
- I have watched the video below and know how to give myself an injection
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
I understand these injections are to be self injected in the frontal thigh area, as portrayed in the video below. 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 or self-injection procedures 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 Agree
SIGNATURE. I HAVE READ THE ABOVE CONSENT FORM AND AGREE TO E-SIGN. (First and Last Name)*
Date SIGNED (mm/dd/yyyy):*
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