Vitassium Club — Application Form
For U.S. residents only.* The Vitassium Club is strictly for individuals with dysautonomia, POTS or EDS that use SaltStick as a medical food. If this describes you, or a child or dependent you care for, then we encourage you to join the Vitassium Club today. Go to vitassium.com to learn more about Vitassium.

To join the Vitassium Club you need to do two things:
(1) Register for a Store Account at shopsaltstick.com
(2) Submit this Vitassium Club Application Form

The Vitassium Club is for U.S. residents only. All Vitassium Club members must have registered at shopsaltstick.com before completing this application. *
The Vitassium Club is strictly for individuals with dysautonomia, POTS, or EDS who use SaltStick products as a medical food. We reserve the right to reject applications at our discretion. *
For whom are you buying SaltStick products? *
Is the individual taking SaltStick for dysautonomia or POTS a female or male? *
How old is the individual taking SaltStick for dysautonomia or POTS? *
Did you find out about the Vitassium Club from one of the following? *
How did you hear about SaltStick products? Please be specific. *
Your answer
What SaltStick products do you use and how long have you been using them? *
Your answer
Your Name (First and Last) *
Your answer
Have you registered for a shopsaltstick.com store account? If not, please create an account before submitting this form. *
What is your shopsaltstick.com login email? *PLEASE NOTE* you must register for an account before you can become a Vitassium Club member. *
Your answer
SaltStick works with doctors, clinics and support groups by providing free product for partners fighting for dysautonomia awareness and cures. What doctor, clinic or support group do you recommend we contact? *
Your answer
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