Patient Intake Form

Patient Intake Form
Prior to scheduling, please submit the below information.
Name of VitaMedics Clinician (leave blank if you don't know)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Would you like to be updated with specials and product information?

YesNo
Address for Requested Appointment

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Height*
Weight (lbs)*
Why are you seeking vitamin IV therapy or injections?*
Have you had an IV or injection previously?

YesNo
If so, did you have any complications?

YesNoHave not had an injection or IV
Please select the INFUSION you are seeking. Select all that apply:

General HydrationLibido EnhancementImmunity BoostSuper Immune BoostHangover TapOutFountain of YouthMenopause MitigatorMyer's CocktailStomach SootherGlutathioneRecovery/Athlete RecoveryNONE - Seeking Injection (see section below)
Please select the INJECTION you are seeking. Select all that apply:

Elevated Energy - Vitamin B12Fat Blaster - Lipo-BBeauty Boost for Hair, Skin and Nails - BiotinSun Kissed - Vitamin D3Pain Relief - ToradolStomach Soother - ZofranAthletic Aid - CoQ10Youth Preservation - Botox/JeuveauPre- and Post-workout - Bi-Amino (Arginine & L-Citrulline)Anti-Inflammatory Antioxidant - GlutathioneMood Enhancer - Vitamin B6 (great for PMS or Depression!)LysineGlycineSuper Heal - BPC157Muscle and Youth Enhancer - SermorelinWeight-Loss Management - SemaglutideNONE - Not seeking injections
How often are you seeking treatment?

DailyWeeklyBi-WeeklyMonthlyUnsure
Allergies (please list all)
Do you have high blood pressure?

YesNo
If so, what medications do you take to control your blood pressure?
Do you have any of the following conditions (select all that apply)?

Congestive Heart FailureKidney FailureCurrently Pregnant or BreastfeedingFluid RetentionEdema or any condition that may cause fluid overloadMastectomy or Lumpectomy (left side)Mastectomy or Lumpectomy (right side)None
Medical History (list any conditions or major surgeries not listed above)
How did you hear about us?
By signing your name below and submitting this form, you are requesting a prescription for vitamin infusion or therapy, weight loss management, or peptide injections. This is not meant to treat any disease or ailments, but provide supplementation. A basic evaluation will be administered at the time of your appointment. If you feel that you are not healthy enough to receive infusion or injection therapy, do not submit this form.

RELEASE FROM MEDICAL LIABILITY AND MALPRACTICE CLAIMS:

I agree to release Dr. Jayson Weir and all his associates from all medical liability and malpractice claims related to any and all care. This consent covers the initial and all future prescriptions for this medication.

I understand that this is a prescription therapy and is not eligible for a refund or reimbursement. You are responsible for proper medication storage and security once it is provided. We will not replace spilled vials of product.

I have read and agree to the above. My questions have been answered and I understand the treatment and goals. If I have any further questions arise, I agree to address them with the clinician prior to any treatment. Once submitted, a team member will contact you to complete the scheduling process.

I certify that I have been informed of the risks and benefits of treatment (label and off-label).

I will review the side effects of all medications I am prescribed and immediately inform the doctor of any side effects.

BY SIGNING BELOW, I INDICATE THAT I'VE READ AND UNDERSTAND ALL THE INFORMATION ABOVE AND WILL ASK QUESTIONS ON ANY AND ALL INFORMATION I DO NOT UNDERSTAND.
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