This form will be sent to one of our Healthcare Providers for review.
Do you have health insurance?* —Please choose an option—YesNo
Gender* —Please choose an option—MaleFemale
Marital Status* —Please choose an option—SingleMarriedDivorcedWidowed
What is your activity level at work* —Please choose an option—Immobile (desk job)Somewhat activeVery Active
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Do you have any of the following conditions?* FibromyalgiaChronic Fatigue SyndromeLiver or Kidney problemsHeart ProblemsHigh Blood PressureThyroid IssuesHormone IssuesPre/Peri/Post MenopauseNone
Have you recently stopped or started smoking?* —Please choose an option—YesNoI've never smoked
Have you recently stopped, started or changed birth control?* —Please choose an option—YesNoI've never smokedI'm a male
Are you taking any blood thinners?* —Please choose an option—YesNo
Are you pregnant or breast feeding?* —Please choose an option—YesNo
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Do you drink alcohol?** —Please choose an option—RegularlySociallyNever
What is your weekly exercise and activity level?* —Please choose an option—I am an Olympic AthleteExercise frequentlyRarelyNever
I understand that my custom package is ordered for me. Any product, supplement, vitamin or package I start at VITAstir will have an expiration date that is 4 months from the day it was started. After the 4 month period, medications are discarded and considered expired. (Some vitamins/supplements vary, please ask nurse at consultation.)* I Agree
Consent to Treatment and other Acknowledgements: By reading and signing this document, I, the undersigned patient (or authorized representative) consent to and authorize the performance of any treatments by Vitastir Health Staff including injections, infusions, examinations, medications, anesthesia, medical services, and surgical or diagnostic procedures (including but not limited to the use of lab and radiographic studies) as ordered or approved by my attending physician(s), or any healthcare professional assigned to my care by my attending physician(s), and I acknowledge and consent to the following: During the course of my care and treatment, I understand that various types of examinations, tests, diagnostic or treatment procedures (“procedures”) may be necessary. These procedures may be performed by physician(s), nurses, technicians, physician assistants, or other healthcare professionals. While routinely performed without incident, there may be material risks associated with these procedures. If I have any questions concerning these procedures, I will ask my physician(s) to provide me with additional information. I also understand my physician may ask me to sign additional Informed Consent documents relating to specific procedures. Anytime an injection is given, there is potential for pain, bruising, or swelling at the injection site. These reactions are fairly mild and self-limited and usually resolve within 24-48 hours. Rare allergic reactions to the injection or infusion may occur. It is important that you inform the health care professional or proceed to the nearest emergency room if you experience severe side effects such as difficulty breathing, lips swelling, hives and chest pain. Physicians and healthcare professionals cannot guarantee any specific result(s) of any examination, treatment, procedure or medical care. I release the Vitastir Health staff, its physicians and healthcare professionals from any liability for any accident or injury that is not directly caused by the negligence of Vitastir Health or its employees.I understand that the healthcare professionals involved in my care will rely on my documented medical history, as well as other information provided by me, my immediate family, or others having information about me, in determining whether to perform or recommend procedures. I agree that I have provided accurate and thorough information regarding my medical history and any conditions or events which may impact medical decision-making. In return for services to be provided by Vitastir Health, I agree to pay for services rendered by Vitastir Health to me or for my benefit. I agree to pay in full for such services at the time the services are received. By signing this document, I certify that I have read and understand its contents and that information provided by me is accurate and any questions I had have been answered to my satisfaction. I believe I have adequate information and knowledge upon which to base an informed consent to the proposed procedure (Injection/Infusion). I am aware of the potential risks involved as outlined.
Date (mm/dd/yyyy):
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