Name *

First Name

Last Name

Phone *

(###)

###

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Which of the following apply? (Check all that apply) *

Fatigue or low energy

Brain fog or forgetfulness

Poor sleep or frequent waking

Slow recovery (workouts, illness, or injury)

Mood swings or low motivation

Increased belly fat or body weight

Decreased muscle mass or performance

Skin issues or premature aging

Frequent illness or low immunity

Duration of symptoms: *

<1 month

1–6 months

6–12 months

Over 1 year

Impact on quality of life (1–10): *

1

2

3

4

5

6

7

8

9

10

Check any that apply: *

Allergy to NAD+, glutathione, peptides, or GLP-1s

Active cancer or treatment within last 5 years

Severe liver or kidney disease

Heart disease or uncontrolled blood pressure

Bleeding disorder or blood thinners

Severe psychiatric illness or bipolar disorder

Pregnant or breastfeeding

Diabetic retinopathy or uncontrolled diabetes

History of pituitary or endocrine disorders

Are you currently taking any prescription medications? *

Yes

No

Are you taking any supplements or herbs? *

Yes

No

Check any categories that apply:

GLP-1s (semaglutide, tirzepatide, etc.)

Blood sugar meds (insulin, metformin, etc.)

Blood pressure meds

Blood thinners or aspirin

Hormones (testosterone, HRT)

Antidepressants or sleep aids

Antioxidants (vitamin C, NAC, CoQ10, resveratrol)

Protein, creatine, or peptides

Have you previously received any of the following? *

GLP-1 therapy (semaglutide/tirzepatide)

NAD+ therapy (IV, injection, or oral)

Glutathione therapy

Sermorelin or other peptides

Vitamin IVs or oral supplement programs

Hormone therapy

Detox or antioxidant protocols

Cognitive or lifestyle coaching

Did any improve your symptoms?

Yes

Somewhat

No

Do you consume alcohol, processed foods, or smoke? *

Yes

Occasionally

No

Did you know... *

● NAD+ declines up to 50% between ages 40–60? ● Glutathione levels drop with age, toxins, stress, and medications? ● HGH declines ~14% per decade after age 30?

Yes — and I’ve felt the difference

I’ve heard of this but didn’t realize the effects

No — this is new to me

Primary Goals (Check all that apply) *

Fat loss / body recomposition

Increased energy or stamina

Mental clarity, focus, or mood

Anti-aging or longevity

Muscle gain / performance

Detoxification or immune support

Better sleep

Recovery from injury, burnout, or stress

Skin health / glow

Support for chronic illness

Other

How soon are you looking to begin if approved? *

Immediately

1–2 weeks

This month

Just learning for now

Which therapies are you most interested in? *

GLP-1s (semaglutide, tirzepatide)

NAD+

Glutathione

Sermorelin

Not sure — need guidance

Preferred method of administration (if approved): *

IV (clinic-based)

Subcutaneous injection (self-administered)

Oral supplements (precursors/liposomal)

Unsure — I’d like help choosing

Comfort with self-injection: *

Very comfortable

Somewhat comfortable

Willing to learn

Prefer professional support