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Product Intake Form
Personalized Protocol for Product Name
Complete this brief assessment to ensure your treatment is safe, effective, and tailored to your goals.
Which benefits or goals best describe why you're taking NAD⁺?
Select up to 3 options that best match your goals.
Selected: 0/3
Daily energy and focus
Mental clarity and cognitive support
Reduce signs of aging
Improve recovery and reduce fatigue
Enhance mood and motivation
Support mitochondrial and metabolic health
Detoxification and resilience after stress or illness
Skin, hair, and appearance benefits
Prevent long-term health decline
Overall vitality and performance
Do any of the following apply to you?
Selected: 0/1
None
Severe uncontrolled high blood pressure
Severe kidney disease (stage 4 or higher) or severe liver disease
History of severe allergic reaction to NAD+ or B-vitamin derivatives
Recent severe cardiovascular event: heart attack, stroke (within 1 year)
Severe cardiovascular condition: unstable angina, uncontrolled arrhythmia
Do any of the following apply to you?
Selected: 0/1
None
Controlled hypertension
Stable cardiovascular disease
Do any of the following apply to you?
NAD+ can cause temporary stimulation which requires awareness of overlapping effects.
Selected: 0/1
None
Taking prescription stimulant medications (e.g., Adderall, Vyvanse, Ritalin, or other ADHD medications)?
Very high caffeine intake or taking nootropic medications
History of severe anxiety or mood disorders
Are you willing to possibly experience mild side effects such as flushing, nausea, or temporary fatigue?
See website and prescribing info for full list.
Yes
No, decline treatment
Do you agree to inform your other healthcare providers that you are starting NAD⁺ therapy and continue regular check-ups with them?
Yes
No, decline treatment
Safety Check
Please review the following.
YOU'RE ALMOST DONE
You're one step away from completing your intake form but we still need your other products medical intake forms.
What happens next:
- Your responses will be securely stored
- You'll be redirected to complete additional product forms
Final Step
COMPLETE SUBMISSION
Thank you for completing your medical intake form, to finish the process please click the submit button.
Your submission is secure and encrypted
- Your provider will review your medical information within 24 hours
- You'll receive an email confirmation shortly
- Questions? Contact support anytime
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