NAD+ Therapy Questionnaire

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We prioritize your health and well-being.

To order your supplements, please complete our comprehensive health questionnaire. This helps us ensure the supplements are right for you. Upon submission, you will be guided through the payment process. In the rare event that your health history indicates the supplements are not suitable, we will promptly refund your payment in full. Approved orders will be shipped within 48 hours.

Order NAD+ Therapy - Questionnaire

Order NAD+ Therapy

New Patient:
Complete below questionnaire and consent
(All new patients to be set up with user name and password)

Returning Patient:
sign in to order

First Name

Last Name

Date of Birth

Gender

Female

Male

Phone/Mobile

Address

Address Line 1

Address Line 2

City

State

Zip Code

Current Medications: (Including prescription, over-the-counter, and supplements)

Allergies: (Medications, foods, or other substances)

Medical Conditions: (Including chronic illnesses, surgeries, and hospitalizations)

Smoking Status: (Current, former, never)

Alcohol Consumption: (Frequency and amount)

Exercise Habits: (Frequency and intensity)

Diet: (General dietary habits, any restrictions)

Sleep Patterns: (Average hours of sleep per night)

Stress Levels: (How would you rate your stress level?)

Reason for seeking NAD+ therapy: (e.g., fatigue, cognitive decline, anti-aging, etc.)

Have you tried NAD+ therapy before? (If yes, please provide details)

Please provide details

Are you currently pregnant or breastfeeding?

Yes, im pregnant and breastfeeding

No, im not pregnant or breastfeeding

Do you have moderate or severe kidney or liver conditions?

Yes, I have kidney or liver condition

No, don't have kidney or liver condition

Do you have any history of heart problems or high blood pressure?

Yes, I have heart problems or high blood pressure

No, don't have heart problems or high blood pressure

NAD+ Injection Consent Form

Patient Information:

Introduction

This consent form provides information about NAD+ (Nicotinamide Adenine Dinucleotide) injections and what to expect during and after the procedure. Please read this form carefully and ask any questions you may have before signing.

What is NAD+?

NAD+ is a coenzyme naturally present in all living cells. It plays a vital role in various bodily functions, including energy metabolism, DNA repair, and cell signaling. NAD+ levels tend to decline with age, and NAD+ injections aim to replenish these levels.

Potential Benefits

While research is ongoing, potential benefits of NAD+ injections may include:

Increased energy levels
Improved cognitive function (memory, focus, mental clarity)
Enhanced mood and well-being
Support for healthy aging
Improved symptoms related to menopause and perimenopause (fatigue, brain fog, mood swings, weight management)
Potential benefits for certain medical conditions (as advised by your physician)

Procedure

NAD+ will be administered via subcutaneous or intramuscular injection.
The dosage and frequency will be determined by your healthcare provider based on your individual needs.

Potential Risks and Side Effects

NAD+ injections are generally safe, but like any medical procedure, there are potential risks and side effects. These can include:

Common Side Effects:
- Pain or discomfort at the injection site
- Redness, swelling, or bruising
- Headache
- Nausea
- Flushing
- Dizziness
- Fatigue
Less Common but More Serious Side Effects:
- Allergic Reactions: Skin rash, itching, hives, difficulty breathing, anaphylaxis (rare but serious).
- Cardiovascular Issues: Changes in heart rate or blood pressure.
- Liver or Kidney Problems: Potential exacerbation of existing conditions.
- Electrolyte Imbalances: May require medical attention.
- Drug Interactions: NAD+ may interact with certain medications.
- Anxiety or Panic Attacks: Temporary anxiety or panic after the injection.
- Insomnia: Difficulty sleeping.

Alternatives

Alternatives to NAD+ injections may include oral NAD+ supplements or other therapies depending on your health goals. Discuss these options with your healthcare provider.

Questions and Concerns

It is important to discuss any questions or concerns you have about NAD+ injections with your healthcare provider before proceeding with the treatment.

Consent

By signing below, I acknowledge that:

I have read and understood this consent form.
I understand the potential benefits and risks of NAD+ injections, including the less common but potentially more serious side effects.
I voluntarily consent to receive NAD+ injections as part of my treatment plan.

First Name

Last Name

Date / Time

Signature

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