1 - NAD+ Questionnaire - SimpleFix Rx

Step 1 of 8

Let's Get Started

First Name*

Last Name*

Email*

Phone*

Height*

Weight*

Date Of Birth*

Month

Day

Year

Sex*

State*

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Medical History

How physically active are you?*

Sedentary

Active but not athletic

Somewhat Active

Athletic

Competitive/Biohacker

Which of the following apply to your reproductive status?*

I am not currently pregnant or breastfeeding

I am currently pregnant or breastfeeding

I plan to become pregnant or breastfeed within next 6months

I am currently going through menopause

I had a hysterectomy or am post-menopause

Do you have any one of the following Medical Conditions?*

Diabetes

Hypertension(High Blood Pressure)

Thyroid condition

Asthma or COPD

Anxiety or depression

HIV OR AIDS

Kidney disease

Cancer

Arrhythmia or irregular heart beat

Vascular disease(stroke, blood clots etc)

HeartFailure

Gallbladder disease

Liver disease

None of the above

Have you ever been told your liver is not working properly?*

Yes

If Yes, Please explain.

Have you ever been told your heart is not pumping properly?*

Yes

If Yes, Please explain.

Do you currently smoke?*

Yes

Do any of your immediate family members have a history of the following conditions?(Check all that apply)

High Cholesterol

Fatty Liver Disease

High Blood Pressure

Pre Diabetes/ Type 2 Diabetes/ Hbac 1 above 5.7

Cancer

Heart disease

Dementia

None of the above

Other

Do you have a primary care provider?*

Yes

Have you had a general health check-up or routine physical in the past three years?*

Yes

Do You have any allergies?*

Yes

If Yes, Please list all.

Do you have any medical conditions our physicians should know about?*

Yes

If Yes, Please list.

Why are you interested in NAD Injections?

Have you ever used NAD+ by patch, IV infusion, injection or nasal spray?*

Yes

Please describe and include any reactions, side effects and/or benefits you may have experienced

Do you feel comfortable drawing up the NAD+ solution and injecting yourself using an insulin-sized needle and syringe?*

Yes

Is there anything else you want to tell your doctor?

READ OUR TERMS & CONDITIONS POLICY

TELEMEDICINE PATIENT CONSENT PURPOSE:

The purpose of "Telemedicine Consent Form" is to get the patient's consent in order to participate in appointments of telemedicine cares.

RECORDS: Telecommunications with patients will not be recorded and stored. Patients' medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies. TELEMEDICINE INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the telemedicine appointment with video and audio.

ACCESS: The patient accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment. PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask the questions related to telemedicine appointments and technical requirements for telecommunication. By signing this form, I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices. I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures. I understand that I can be charged the additional fees that my insurance does not cover. I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis.

I agree to terms and conditions*

I agree to terms and conditions

By using SimpleFix you are consenting to the practices described in the privacy policy*

By using SimpleFix you are consenting to the practices described in the privacy policy

Sign & Consent

I consent to receive NAD+ (nicotinamide adenine dinucleotide) therapy from my provider. I understand this is an off-label wellness treatment, not FDA-approved for any specific condition. It may be administered by IV, IM, or subcutaneous injection. Benefits may include improved energy, mood, and focus; side effects may include nausea, flushing, rapid heart rate, or injection site discomfort. Results are not guaranteed. I may stop treatment at any time and have discussed alternatives. I confirm I have no history of cancer, current cancer, or genetic cancer risk. I have disclosed my medical history, will report any side effects, and all questions have been answered.

Sign here*

Shipping & Billing Information

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Billing Address*

Same as Shipping Address

Street Address Address Line 2 City State ZIP Code

NAD - Anti- Aging

NAD $185/ - month

NAD $320/ - 2 month

Available Add-ons (Optional)

Product Name

The benefits of NAD+ injections can vary, most patients report feeling energetic, mental clarity, improved mood and

Shipping Options

Please allow 4 days (48 hours for the physician, 48 hours for the pharmacy) to review and process your order.

Shipping*

Standard Shipping

Standard Shipping with Insurance

SimpleFixRx is not liable for packages lost or stolen during transit. Once your order is handed over to the carrier, both the carrier and you are responsible for the package. To ensure your package during transit, please select the second shipping option, which includes insurance for an extra $10.

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Credit Card*

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Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

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Expiration Date Month Year

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