SimpleFix Patient Intake

1. Patient Information

First Name *

Last Name *

Email *

Phone *

Date of Birth *

Sex *

Female Male

State *

Returning Patient?

Yes, I'm a returning patient No, I'm a new patient

2. Measurements & Goals

Weight (lbs) *

Height (Feet) *

Height (Inches) *

BMI

What are your primary weight-loss goals?

Lose 1–20 lbs Lose 21–50 lbs Lose over 50 lbs Maintain my healthy weight None of the above

What are your top-priority goals for hair loss treatment?

Prevent further hair loss Regrow hair Fuller/thicker-looking hair Maintain a full head of hair

How satisfied are you with your hair overall?

Not at all A little bit Somewhat Quite a bit Very

Where are you noticing hair loss or thinning?

Both hairline and crown Receding hairline Thinning crown Overall thinning Random golf-ball-size bald patches

3. Lifestyle & Activity

How physically active are you? *

What type of exercise do you do?

What weight-loss initiatives have you tried in the past?

4. General Medical History

Have you seen a doctor in the past 12 months? *

Yes No

Do you have a primary care provider? *

Yes No

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

Yes No

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

Yes No

Medical conditions — please list if applicable

5. Additional Medical Screening

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

Yes No

If yes, please explain

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

Yes No

If yes, please explain

Have you had serious gallbladder issues within the past 12 months? *

Upper abdominal pain Yellowing of skin or eyes Clay-colored stools Active gallbladder disease No, none of these

Have you been diagnosed with pancreatitis in the past 6 months?

Yes No

Have you been diagnosed with kidney disease in the past 12 months? *

Yes No

Have you ever been diagnosed with medullary thyroid cancer or MEN syndrome? *

Yes No

Do you have an active eating disorder? *

Yes No

Have you had bariatric surgery within the past 18 months? *

Yes No

Are you currently struggling with substance abuse or dependency problems? *

Yes No

Have you noticed any of the following scalp or hair-related symptoms?

Redness or rashes Pain, soreness, burning or tingling Pus bumps or open sores Loss of eyebrows or eyelashes Loss of body hair None of the above

What is your current reproductive status? *

Not currently pregnant or breastfeeding Currently pregnant Currently breastfeeding Planning pregnancy within the next 6 months Planning pregnancy within the next year Currently going through menopause Hysterectomy / post-menopause None of the above

6. Medications & Allergies

Current medications, supplements and topical products *

Additional medication information

Do you have any allergies? *

Yes No

Are you allergic to any of the following?

Finasteride — oral or topical Minoxidil — oral or topical Ketoconazole — oral or topical Latanoprost None of the above

Please list all known allergies. *

7. Weight-Loss Treatment History

Have you previously used weight-loss medication? *

Yes No

Have you taken any GLP-1 weight-loss medications? Please list all medications. *

Did you previously purchase your weight-loss medication from SimpleFix? *

Please tell us where you filled your last weight-loss medication.

What was your most recent medication and dosage strength? *

Would you like your prescription strength increased? *

Yes — I am experiencing slow/plateaued weight loss and would like an increase according to protocol. No — I am happy with my current progress.

Did any of the following side effects cause you to discontinue treatment? *

Please describe any other side effects you experienced

8. Hair-Loss Treatment History

Have you ever treated your hair loss with medication? *

Yes No

What treatments have you received?

Oral minoxidil Topical minoxidil / Rogaine Oral finasteride / Propecia Topical finasteride Steroid injections in the scalp Other

Please tell us more about your hair-loss treatment experience.

9. NAD+ & Wellness History

Why are you interested in NAD+ injections?

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

Yes No

Please describe your experience, including reactions, side effects and/or benefits.

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

Yes No

Have you been diagnosed with vitamin B12 deficiency by a physician or other healthcare professional? *

Yes No

Do any of the following apply to you?

Leber's optic neuropathy Polycythemia Vera Gout Low potassium levels Anemia other than low vitamin B12 None of the above

What benefits are you seeking?

Do any of the following apply to you?

Active cancer diagnosis Disease of the pituitary gland Untreated hypothyroidism Uncontrolled diabetes Intracranial lesion/tumor None of the above

10. Family History, Smoking & Hormone Health

Do any of your immediate family members have a history of the following conditions?

Do you currently smoke? *

Yes No

Are you currently on hormone therapy?

Creams Pellets No, I am not on hormone therapy Not currently, but I should be I am happy with my hormone health

In the past 12 months, which best describes your mental health?

I experienced no mental health problems. I am on medication but feel in control. I deal with stress but do not take medication.

11. Additional Information & Consultation Preference

Is there anything else about your medical history, medications, symptoms, or treatment goals that you would like your provider to know?

Which type of consultation would you prefer? *

Video Phone Asynchronous / Email and Text Message — Fastest Option

12. Add-ons

Optional — select any add-ons you'd like included with your bundle. Each one is reviewed and prescribed by your doctor alongside your bundle.

Available Add-ons

4 mg Ondansetron Anti-Nausea Pills, 30-Count $30.00 B12 - one month supply IM $79.00 L-Glutathione - Monthly $135.00 Lipo-B - one month supply $90.00 NAD - Anti-Aging - Monthly $185.00 Sermorelin 10ml - muscle building $165.00

The Complete Bundle $499.00

Total $499.00

13. Terms, Privacy & Signature

Please review the applicable Terms and Conditions and Privacy Policy before submitting this form.

I agree to the Terms and Conditions. *

By using SimpleFix, I consent to the practices described in the Privacy Policy. *

By signing below, I confirm that the information I have provided is complete and accurate to the best of my knowledge. I understand that treatment decisions are made by the treating healthcare provider after review of my information.

Patient Signature *

Printed Name *

Date *

14. Shipping & Billing

Please provide the address where your approved order should be shipped.

Shipping Method *

Standard Shipping +$25.00 Standard Shipping + Insurance +$35.00

Shipping Address

Street Address *

Address Line 2

City *

State *

ZIP Code *

Billing Address

Billing address is the same as shipping address

Street Address

Address Line 2

City

State

ZIP Code