Qualification Questionnaire

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How did you hear about us?

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Friend

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Please select your state

Select your state to see treatments

available to you

I am at least 18 years old.

By clicking this box, I acknowledge that I have read, understood, and agree to the Terms of Use, Privacy Policy, Telehealth Informed Consent, Cancellation Policy and acknowledge the Notice of Privacy Practices

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Introduce yourself

Your name will be used by our providers to personalize your treatment (if qualified).

First Name

Please specify an answer

Last Name

Please specify an answer

Date of Birth

Please select a valid date.

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What is your address @First-Name?

Our pharmacy will use this information to ship your personalized treatment

(if qualified).

Address

Please specify an answer

Apartment # (If applicable)

Please specify an answer

City

Please specify an answer

State

Please specify an answer

Zip Code

Please specify an answer

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Contact information

What is your email address?

Please specify an answer

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Do you have any known allergies to NAD+, niacinamide, or nicotinamide?

Yes

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What is your primary reason for seeking NAD+ treatment?

Select one or more:

Boost energy and reduce fatigue

Improve focus or mental clarity

Support cardiovascular health

Support recovery from addiction or substance use

Anti-aging or longevity

Athletic performance or muscle recovery

Improve sleep or reduce brain fog

Support mood or reduce anxiety

Other

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Do you currently have or have ever been diagnosed with any of the following?

Check all that apply:

Heart disease or congestive heart failure

Stroke or mini-stroke (TIA)

Uncontrolled high or low blood pressure

Diabetes or insulin resistance

Liver disease (e.g., hepatitis, cirrhosis)

Kidney disease or reduced kidney function

Cancer (current or past)

Mitochondrial disorders

None of the above

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Have you received NAD+ therapy before?

Yes

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Are you currently taking any medications that may affect your cellular metabolism or NAD levels?

Yes

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Have you experienced any of the following symptoms in the past 6 months?

Check all that apply:

Chest pain

Shortness of breath

Dizziness or fainting

Irregular heartbeat or palpitations

None of the above

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Are you currently pregnant, trying to become pregnant, or breastfeeding?

Yes

Do you currently take any medications, vitamins, or supplements on a regular basis?

Yes

What medications, vitamins, or supplements are you currently taking?

Please list the name,and how

often you take each one.

Please specify an answer

Have you completed any blood work in the past 60 days?

If you have, please upload a copy of your most recent blood work results.

Accepts png, jpeg, pdf

Almost there @First-Name

Analyzing Your Information

We’re carefully reviewing your responses to understand your health needs and goals.

Matching You With a Provider

Based on your information, we’re selecting the most appropriate licensed provider to guide your care.

Creating a Personalized Plan

Your data helps us determine the best first step in your treatment journey—tailored just for you

Preparing Your Recommendations

We’re finalizing your personalized treatment options. You’ll see them shortly, along with your next steps.

Congratulations 🎉

Based on your answers, a

provider may consider this

treatment:

$399/Month

$999/3 Month Treament

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