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.

  • Feet and Inches (Example: 5' 1")
  • Please fill out as completely as possible.
  • (In case of emergency)
    Check ALL that apply
    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
  • Date Format: MM slash DD slash YYYY