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All questions contained in this questionnaire are strictly confidential.

First Name *

Last Name *

Email *

Phone *

Street Address *

City *

Postal code *

State *

Have you ever had an adverse or allergic reaction to NAD (nicotinamide adenosine dinucleotide), NR (nicotinamide riboside)? (if yes please explain) *

Have you previously received NAD IV infusions, IM injections, Nasal Spray or topical? If Yes, What dose? *

Are you currently receiving NAD IV infusions, IM injections, Nasal Spray or topical anywhere else? (If yes, at what dose?) *

Are you currently taking any NAD supplements (NAD, NR-nicotinamide ribose or NMN- nicotinamine mononucleotide)? If yes, which supplement and at what dose? *

During your NAD IV infusions, IM injections, Nasal Spray or topical have you experienced any of the following adverse or allergic reactions? (if yes, explain) *

Are you currently taking any NAD supplements (NAD, NR or NMN?) If yes, which supplement and at what dose? *

Do you have history of heart disease? *

Yes

No

Do you currently have cancer or a history of cancer? (If yes, what type of cancer?) *

Any significant family history of cancer (in relatives such as parents or siblings)? If yes, type of cancer: *

PATIENT CONSENT & PAYMENT

I have received information on the risks and benefits of Nicotinamide Adenine Dinucleotide (NAD) screening and treatment and fully understand them. I have also had the opportunity to ask any questions.

I consent to undergoing the NAD screening and, if appropriate, to receiving treatment as recommended by my healthcare provider. I understand that I may withdraw my consent at any time by informing my provider.

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