Consultation Step 1 of 7 - Goals 14% I NEED HELP WITH...(Required) Weight Loss Sexual Health Energy Low Libido Hormone Balance How often does this issue bother you?(Required) Daily Often Rarely Email(Required) Enter Email Confirm Email New Patient or Existing Patient?(Required) New Patient Existing Patient Have you previously treated this issue?(Required) Yes No What has worked in the past?(Required) Name of treatments and dosages that have worked for you in the past. If none, write none.What type of solutions are you interested in today?(Required) Pills Injections Lotions Do you have any of the following conditions?(Required) High/Low Blood Pressure Heart Related Issues Irregular heart rhythm Liver or Kidney Issues Chest Pain or Angina Multiple Myeloma, Leukemia or Sickle Cell Anemia Retinopathy Narrowing of the aortic heart valve Hypertrophic cardiomyopathy Stroke Vision or hearing loss NONE Past Medical and Surgical history?(Required) What medications are you currently taking?(Required) Name(Required) First Last Picture ID(Required)Max. file size: 256 MB.(Drivers License, Passport or government issued Picture ID)Which state do you live in?(Required) State Date of Birth(Required) Height(Required) Weight(Required) Race(Required) (We ask this because some populations are more susceptible to certain conditions than others.)Sex(Required) Male Female Allergies(Required) What is your occupation?(Required) Do you have pancreatitis or a history of pancreatitis?(Required) Yes No Do you have medullary thyroid cancer or a history of medullary thyroid cancer?(Required) Yes No Do you have renal (kidney) impairment?(Required) Yes No Do you have type 1 diabetes or diabetic retinopathy?(Required) Yes No Are you taking any blood thinners?(Required) Yes No I understand that if I am taking anti-coagulants (blood thinners) then I may have delayed clotting when giving myself an injection. I understand that in this circumstance I may bleed a little more then the usual patient. If I have any questions about this I will discuss with my nurse at [email protected].(Required) I understand and I AGREE Are you pregnant or breast feeding?(Required) Yes No I'm a male Prescription Medications OR Non-Prescription Supplements you are currently taking:(Required) Do you have any new prescription Medications OR Non-Prescription Supplements you are currently taking?(Required) Do you drink alcohol?(Required) Yes No It is not recommended that you consume alcohol on the same day of your injection.(Required) I Understand Phone Number(Required)Please provide the best number where our physician can contact you.Secondary Phone Number (optional)Please provide the best number where our physician can contact you.BILLING ADDRESS(Required) Street Address Address Line 2 City 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 Pacific State ZIP Code Billing Address Same as Shipping Address?(Required) Yes No SHIPPING ADDRESS(Required) Street Address Address Line 2 City 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 Pacific State ZIP Code REQUIRED "HOW TO" VIDEOS(Required) I have watched the videos and know how to give myself an IM & SUB-Q injection www.citizenmeds.com/howtoinject (2 VIDEOS AVAILABLE HERE)PROPER USE: Pills/Injections(Required) [Injections]: I understand these injections are to be self injected in the frontal thigh area, as portrayed in the video (WWW.CITIZENMEDS.COM/HOWTOINJECT). I agree I will use the syringes and vitamins as directed. [Pills]: I understand that my prescription medications are only to be used by me. My pills at Citizen Meds will have an expiration date that will be on my bottle. Injectables: Once the vials are opened, are to be discarded 30 days after opening. I understand , after the 30 day period, injectable vials are considered expired and should be discarded by me.Injection Consent(Required) CONSENT FORM: I acknowledge that I have received instructions and educational material from Citizen Meds 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 Citizen Meds as needed. By signing this form, I assume full responsibility for receiving my injections and release Citizen Meds and its physicians from any liability or responsibility for any reactions, conditions, self-injection procedures or injuries in conjunction with the injection therapies.Pills and Medication Consent(Required) CONSENT FORM: I agree to properly use my medications responsibly as indicated on the instructions I receive on my prescription vial. I acknowledge that I understand and have received instructions and educational material from Citizen Meds for my medications. I acknowledge that the risks have been discussed with me. 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 Citizen Meds as needed. By signing this form, I assume full responsibility for receiving my medication and release Citizen Meds and its physicians from any liability or responsibility.I UNDERSTAND THIS IS A NON-REFUNDABLE PRODUCT AND CANNOT BE RETURNED. I AGREE TO THE REFUND POLICY AVAILABLE AT www.citizenmeds.com/refund-policy/ - I authorize CITIZEN MEDS 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.(Required) I AGREE I agree to give my consent to treat. I have read the Telehealth Consent located at www.vitastir.com/consent(Required) I AGREE I agree to CITIZEN MEDS Terms and Conditions. I have read the Terms and conditions located at https://www.citizenmeds.com/terms-and-conditions/(Required) I AGREE PRINT NAME. I HAVE READ THE ABOVE CONSENT FORM AND AGREE TO E-SIGN. (First and Last Name)(Required) Signature: By signing below, I hereby acknowledge that the above statements are true and correct to the best of my knowledge.(Required)Date SIGNED (mm/dd/yyyy):(Required) ONE-TIME OR SUBSCRIPTION ORDER? ONE-TIME ORDER ONLY RECURRING SUBSCRIPTION MONTHLY (Subscription will be charged on this day every month. Cancel anytime before next billing by emailing [email protected] ) ***IMPORTANT*** YOU ARE AGREEING TO A SUBSCRIPTION PROGRAM I AGREE TO A MONTHLY SHIPMENT AND AUTOMATIC BILLING TO MY CREDIT CARD ON THIS DAY EVERY MONTH (IF YOU DO NOT WANT THIS OPTION, CLICK "ONE TIME ORDER' IN THE PREVIOUS QUESTION) Δ