VitaShots Mobile New Patient Form 2024

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Are you a new client or returning patient?* This field is required.
NEW
RETURNING
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Are there any changes in your personal information since your last visit? This includes, name changes, phone number, address, email address.
YES
NO
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Have there been any changes to your medical history since your last visit?
YES
NO
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Today's Date
Today’s Date
Month
Day
Year
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Full Name* This field is required.
First Name
Last Name
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Address* This field is required.
Street Address
Street Address Line 2
City
County
Post Code
United States
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The Bahamas
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Barbados
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Belize
Benin
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Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
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Canada
Cape Verde
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Central African Republic
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Chile
China
Christmas Island
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Colombia
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Cook Islands
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Cote d'Ivoire
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Cuba
Curaçao
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The Gambia
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Greece
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Guadeloupe
Guam
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Guinea
Guinea-Bissau
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Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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E-mail* This field is required.
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Do you want to receive monthly emails and reminders from VitaShots Mobile, including our monthly calendars, shot of the month information, discounts and specials, closure information, and helpful tips for healthy living. You may unsubscribe at any time* This field is required.
Yes
No
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Cell Phone Number* This field is required.
Area Code
Phone Number
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Are you already receiving our text notifications? (If not and you want to, the next question allows you to opt in to receiving them.)
YESNO
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Do you want to receive text notifications and reminders of when we will be at this clinic. We send out weekly or biweekly reminders the morning of our clinics. We will also send a text if clinic is canceled, delayed or changed for any reason. You can opt our at any time by responding STOP* This field is required.
Yes
No
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Date of Birth* This field is required.
Month
Day
Year
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Upload your photo ID or Drivers License by uploading it now- If you do not have an ID on file you will be asked to provide your ID at every visit. Placing your ID on file now will save you time each visit. If you are unable to upload it at this time ask us when you come in to place it on your file.Click Browse Files and access the camera on the device you are using
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Where did you first hear about VitaShots Mobile?
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Which Clinic Location are you at today or will you be attending?* This field is required.
Bay City
Carthage
Conroe
Deer Park
Henderson
Huntsville
Jacksonville
Jasper
Kilgore
Livingston
League City
Longview
Lufkin
Marshall
Nacogdoches
Pasadena
Pearland
Timpson
Woodville
Other
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BMI Calculator - Put in your weight in pounds and your height to calculate your current Body Mass Index or BMI - Using the chart below to see if you are normal range.This is only required for weight loss only
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If BMI is 25 or more - ask about our weight loss regimen.
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Do you have known sensitivity to cobalt or Early Leber’s Disease ( hereditary optic nerve atrophy)?* This field is required.
Yes
No
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Do you have known Urine Maple Disease?* This field is required.
Yes
No
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Do you have ALS or Lou Gehrig’s Disease?* This field is required.
Yes
No
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Are you pregnant or post-partum (< 6 weeks)?* This field is required.
Yes
No
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Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?* This field is required.
Yes
No
Other
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Now let's talk about what brought you in today? Based on your answers you choose below you will be given possible speciality cocktail suggestions as well as individual vitamin and amino acid suggestions. This is for informational purposes only to help you decide which you should start with.
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Want suggestions based on what you want? Select all that apply
I want more energy
I want to lose weight
I want a healthier liver
I want to help muscle performance
I want better mental clarity
I want to sleep better
I want to strengthen my immune system
I want clearer skin and better complexion
I am an Athlete and want better peformance
I am looking for muscle recovery and repair
I want to learn about a healthier lifestyle
I want to improve my heart health
I would like help with bloating
I would like reduction in stress and anxiety
I would like information on everything listed above
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You must stay in the building for 10 minutes after receiving your first injection of any new to you vitamin or amino acid.

By signing below, I have read the information provided regarding the requested injection, and I have had a chance to ask questions. I understand all the benefits and risks and request that the injection to be given to myself or to the person named for whom I am authorized to make this request. I will not hold my workplace, the place of clinic, VitaShots Mobile LLC, or the Medical Director Dr Maxine Thomas, responsible and I assume full responsibility for any reactions that may result.
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Signature* This field is required.
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