Product Consulting Product Name- Select Product-BCPEpitalonGHK-CUKPVInjectable Semaglutide with additivesSublingual SemaglutideOzempicWegovyZepboundMounjaroInjectable Tirzepatide with additivesInjectable Lipo-CInjectable Lipo-BInjectable NAD+NAD+ CreamNAD+ Nasal SprayInjectable GlutathioneInjectable B-12Sermorelin InjectableViagraSildenafilTadalafilCialis TabletsFemale Estradiol GelFemale Estradiol TabletsFemale Estradiol PatchEnclomiphene TabletsMinoxidil TabletsFinasteride TabletsMinoxidil / Finasteride / Retinoic Acid Topical SolutionComing SoonComing SoonComing SoonComing SoonSize1 MonthSize1 Month3 Month6 MonthSize 1 MonthSize 1 MonthSize 1 MonthSize 1 MonthSize 1 MonthSize 1 Month3 Month6 MonthSize1 Month3 Month6 MonthSize1 Month3 Month6 MonthSize1 Month3 Month6 MonthSize1 MonthSize1 MonthSize1 MonthSize1 Month3 Month6 MonthSize1 MonthSize1 MonthSize1 MonthSize1 MonthSize1 MonthSize1 Month3 MonthSize1 Month3 MonthSize1 MonthSize1 MonthSize1 MonthSize1 Month WHAT ARE YOUR GOALS? Check ALL that apply Energy Weight Loss Perfomance / Lean Help my Deficiency Hormone Balance / Fertility / PCOS Immune Boost Skin Help with Depression General Wellness Mood / Focus / Stress Inflammation Detox OtherEmailNo payment items has been selected yetPreviousNextWhat State do you live in?- Select -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 PacificPreviousNextAnd InchesHeight (feet)Weight (lbs) Which options would you like? - (If physician does not approve, this amount will be fully refunded.) Most Popular: NAD+ Injection Homekit - ACTIVATED FORM (20 doses) *SALE* QuantityPrice: $135.00QuantityGlutathione Homekit (10 doses, 30 day supply) *SALE* QuantityPrice: $79.00QuantityNo payment items has been selected yetPreviousNextIS THIS YOUR FIRST HOMEKIT?*- Select -New PatientRefill OR Existing PatientFirst NameLast NamePLEASE USE YOUR LEGAL FIRST NAME ONLY. ANY OTHER NICK NAMES OR VARIANCES WILL CAUSE DELAYS IN YOUR ORDER. PLEASE USE YOUR LEGAL LAST NAME ONLY. ANY OTHER NICK NAMES OR VARIANCES WILL CAUSE DELAYS IN YOUR ORDER. PreviousNextDate of BirthAny new allergies?Do you have pancreatitis or a history of pancreatitis? Yes NoDo you have medullary thyroid cancer or a history of medullary thyroid cancer? Yes NoDo you have renal (kidney) impairment? Yes NoDo you have type 1 diabetes or diabetic retinopathy? Yes NoAre you taking any blood thinners? Yes NoDo you have any new prescription Medications OR Non-Prescription Supplements you are currently taking?PreviousNextHave you previously taken a GLP before such as Semaglutide, Tirzepatide, Ozempic, Wegovy, Mounjaro etc.? Yes NoDo you have any of the following conditions? High Blood Pressure High Cholesterol High Blood Sugar NONEDo you have any of the following? SELECT ALL THAT APPLY High Waist Circumference Sleep Apnea Food Addiction Family History of Obesity NonePreviousNextPhone/MobileBilling AddressStreetCityStateZip CodeBilling Address Same as Shipping Address? Yes NoShipping AddressStreetCityStateZip CodePreviousNextI WILL FOLLOW THE INSTRUCTIONS AND DOSAGE AMOUNTS ON MY BOTTLE. I understand these injections are to be self injected in the area written on my bottle. I will watch the video to learn how to self-inject. I am aware the instructional video is available to watch at www.vitastir.com/howtoinject. I agree I will use the syringes and vitamins as directed.* I AgreeI understand that my custom package is ordered for me. My vial or package I start at VITAstir will have an expiration date that is 28 days after opening. I understand, after the 28 day period, medications are considered expired and should be discarded by me.* I AgreeI understand that my medication is prepared in a compounding pharmacy in accordance with Section 503A of the Federal Food, Drug, and Cosmetic Act and is dispensed solely pursuant to a valid patient-specific prescription from a licensed healthcare provider. If I am ordering Tirzepatide, I undertand the following: This compounded medication contains Tirzepatide combined with glycine and vitamin B12, and is formulated specifically for individual patients who may not tolerate standard formulations or who require a customized therapeutic approach. It is prepared in accordance with Section 503A of the Federal Food, Drug, and Cosmetic Act and is dispensed solely pursuant to a valid patient-specific prescription from a licensed healthcare provider. Our compounded formulation is not affiliated with, endorsed by, or intended to replace the FDA-approved product manufactured by Eli Lilly. The addition of glycine and vitamin B12 is intended to support patients experiencing issues such as fatigue, muscle loss, or neuropathy—common concerns during weight loss or diabetes treatment—and may offer metabolic, neurological, and musculoskeletal benefits. This medication is not made for resale, bulk distribution, or office use, and is compounded exclusively to meet the clinical needs of individual patients when commercially available alternatives are not appropriate.* I AgreeCONSENT 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 also understand that I am able to use VITAstir services and go to any pharmacy of my choosing.* I AgreeNO RETURNS - 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 AgreeI agree to give my consent to treat. I have read the Telehealth Consent located at www.vitastir.com/consent* I AgreeI agree to VITAstirs Terms and Conditions. I have read the Terms and conditions located at https://www.vitastir.com/terms-and-conditions/* I AgreePRINT NAME. I HAVE READ THE ABOVE CONSENT FORM AND AGREE TO E-SIGN. (First and Last Name)*Date SIGNED (mm/dd/yyyy):PreviousNext (If physician does not approve, this amount will be fully refunded.) Total Previous Submit Form
