Consult Step 1 of 9 - CONTACT INFO 11% First Name Last Name* Signature* Email* Enter Email Confirm Email Phone Number* This is the Phone Number the Doctor will use to call you. Please double check to make sure that it is correct.Are you new to us?*New PatientRefill OR Existing Patient Which options would you like to talk to the Doctor about?All Homekits are a 1 month supply.B12 Homekit Quantity Price: $164.00 Quantity Lipotropic(MIC)/B12 Homekit Quantity Price: $199.00 Quantity Skinny Shot Homekit Quantity Price: $339.00 Quantity Vitamin C Homekit Quantity Price: $229.00 Quantity PowerShot Homekit Quantity Price: $399.00 Quantity Immune Boost Homekit Quantity Price: $599.00 Quantity Glutathione Homekit Quantity Price: $249.00 Quantity L-Carnitine Homekit Quantity Price: $199.00 Quantity B-Complex Homekit Quantity Price: $229.00 Quantity Folic Acid Homekit Quantity Price: $149.00 Quantity B1 (Thiamine) Homekit Quantity Price: $149.00 Quantity B5 (Dexapanthanol) Homekit Quantity Price: $139.00 Quantity Balance Homekit Quantity Price: $659.00 Quantity Skin Bright Homekit Quantity Price: $478.00 Quantity Vitamin D Homekit Quantity Price: $399.00 Quantity Coupon Choose a Shipping Option:*Standard USPS Flat RateFedex One Rate (2-3 Days)Fedex Standard Overnight (M-F)Fedex Priority Overnight (Delivered M-Sat)Total $0.00 You will not be charged until after the physician reviews and approves your medication. 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 the reason for your consultation?* 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 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 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 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):* CAPTCHA You will not be charged until the Physician reviews and approves your medication.TOTAL BEING CHARGED NOW: $0Credit Card* Exp* CVC* Billing Zip* Cardholder Name* Δ
