Sample Requisition

Sample Submission

Please submit Monday-Thursday ONLY
Ordering clinician*
SapereX sample ID*
Sample collection date*

MonthDayYear
Date
Today's date

MonthDayYear
Date
SapereX samples should be entered into the submission portal and shipped on the date of sample collection. Please describe the deviation.
Why is the sample collection date not today?
Time*

Hour Minutes

AM/PM Option
SapereX blood collection tube lot #
Technician initials*
Visit number*

1234567891011121314
Visit number*
Tracking number*
Shipping from (City, State)*
Chronological age*
Gender*

MaleFemale
This individual does not meet testing requirements. Please contact support@sapere-bio.com for more information.
Comments
Current Longevity Interventions
Please select CURRENT longevity interventions (in last 6 months)

HormonesTherapeutic plasma exchangeNAD+ or derivativesStem cell or gene therapyRapamycinHuman growth hormoneSenolytic supplementsThymosin alpha 1GLP-1 agonistsNK-cell therapySGLT2 inhibitorsPeptidesMetforminOther longevity interventionNONE
Hormones

EstrogenProgesteroneTestosteroneOther
Estrogen brand or source
e.g., Rx
Estrogen route

OralTransdermal patchTopical cream or gelVaginalOther
Estrogen dose
e.g., 0.0375 mg
Estrogen frequency

Daily2x weeklyWeeklyOther
Other estrogen info
e,g., start date, duration, dose changes, etc
Testosterone brand or source
e.g., Rx
Testosterone route

OralTransdermal patchTopical cream or gelInjectionOther
Testosterone dose
e.g., 50 mg
Testosterone frequency

DailyWeekly2x per monthOther
Other testosterone info
e,g., start date, duration, dose changes, etc
Progesterone brand or source
e.g., Rx, compounded
Progesterone dose
e.g., 50 mg
Progesterone frequency

DailyOther
Other progesterone info
e,g., start date, duration, dose changes, etc
Senolytics

QuercetinDasatinnibFisetinCombination senolyticOther
Fisetin brand or source
Fisetin route

OralTopical cream or gelOther
Fisetin dose
e.g., 100 mg capsules
Fisetin frequency

DailyWeeklyOther
Other fisetin info
e,g., start date, duration, dose changes, etc
Quercetin brand or source
Quercetin dose
e.g., 100 mg capsules
Quercetin frequency

DailyWeeklyOther
Other quercetin info
e,g., start date, duration, dose changes, etc
Dasatinib brand or source
e.g., Rx
Dasatinib dose
e.g., 100 mg capsules
Dasatinib frequency

DailyWeeklyOther
Other dasatinib info
e,g., start date, duration, dose changes, etc
Combination product brand or source
Combination product dose
e.g., 100 mg capsules
Combination product frequency

DailyWeeklyOther
Other combination product info
e,g., start date, duration, dose changes, etc
NAD+ or derivatives

NAD+NRNMNOther
NAD+ brand or source
NAD+ route

OralInjectionInfusionOther
NAD+ dose
e.g., 100 mg
NAD+ frequency

Daily2x per weekWeekly2x per monthOther
Other NAD+ info
e,g., start date, duration, dose changes, etc
NMN brand or source
NMN dose
NMN frequency

DailyWeeklyOther
Other NMN info
e.g., start date, duration, dose changes, etc.
NR brand or source
NR dose
NR frequency

DailyWeeklyOther
Other NR info
e.g., start date, duration, dose changes, etc.
Rapamycin brand or source
e.g., Rx, AgelessRx, compounded
Rapamycin dose
e.g., 6 mg weekly
Rapamycin frequency

DailyWeeklyOther
Other rapamycin info
e.g., start date, duration, pulse interval, peak/trough
Metformin brand or source
e.g., Rx, AgelessRx
Metformin dose
e.g., X mg
Metformin frequency

DailyOther
Other metformin info
e.g., start date, duration, dose changes, etc.
Urolithin A brand or source
e.g., Mitopure
Urolithin A dose
e.g., X mg
Urolithin A frequency

DailyOther
Other Urolithin A info
e.g., start date, duration, dose changes, etc.
Calcium alpha-ketoglutarate brand or source
e.g., ProHealth, DoNotAge
Calcium alpha-ketoglutarate dose
e.g., X mg
Calcium alpha-ketoglutarate frequency

DailyOther
Other calcium alpha-ketoglutarate info
e.g., start date, duration, dose changes, etc.
Acarbose brand or source
e.g., Rx
Acarbose dose
e.g., 100 mg
Acarbose frequency

DailyOther
Other acarbose info
e.g., start date, duration, dose changes, etc.
Spermidine brand or source
e.g., Life Extension, DoNotAge
Spermidine dose
e.g., 100 mg
Spermidine frequency

DailyOther
Other spermidine info
e.g., start date, duration, dose changes, etc.
Human growth hormone brand or source
e.g., Rx
Human growth hormone dose
e.g., mg or IU (please specify)
Human growth hormone frequency

WeeklyMonthlyOther
Other human growth hormone info
e.g., start date, duration, dose changes, etc.
Therapeutic plasma exchange frequency

WeeklyMonthlyOther
Therapeutic plasma exchange
e.g., start date, planned duration, location, provider, protocol, etc.
Stem cell or gene therapy
e.g., start date, planned duration, location, provider, protocol, etc.
Prolon info
e.g., start date, planned duration, etc.
SGLT2 inhibitor

Farxiga (dapagliflozin)Invokana (canagliflozin)Jardiance (empagliflozin)Steglatro (ertugliflozin)Other
SGLT2i dose
e.g., 100 mg
SGLT2i frequency

DailyOther
Other SGLT2i info
e.g., start date, duration, dose changes, etc.
GLP-1 agonist

Adlyxin (lixisenatide)Bydureon (exenatide)Byetta (exenatide)Mounjaro (semaglutide)Ozempic (semaglutide)Rybelsus (semaglutide)Trulicity (dulaglutide)Victoza (liraglutide)Wegovy (semaglutide)Zepbound (tirzepatide)Other
GLP-1 dose
e.g., 0.6 mg
GLP-1 frequency

Twice dailyDailyWeeklyOther
Other GLP-1 info
e.g., start date, duration, dose changes, etc.
Date

MonthDayYear
Date
Please select longevity interventions DISCONTINUED (in last 6 months)

HormonesTherapeutic plasma exchangeNAD+ or derivativesStem cell or gene therapyRapamycinHuman growth hormoneSenolytic supplementsThymosin alpha 1GLP-1 agonistsNK-cell therapySGLT2 inhibitorsPeptidesMetforminOther longevity interventionNONE
Clinical History
Please let us know if the client has any of the following aging or immune-related conditions

Heart diseaseDiabetesCancerAuto-immune diseaseGastrointestinal diseaseOther aging or immune-related conditionNONE
Please provide details about onset, duration, management of heart disease
Please provide details about onset, duration, management of diabetes
Please provide details about onset, duration, management of cancer
Please provide details about onset, duration, management of GI disease
Please provide details about onset, duration, management of autoimmune disease
Please provide details about onset, duration, management of other aging or immune-related conditions
Lab Measures
Please select labs measured within the last six months

ApoBLp(a)GlucoseHbA1cInsulinVO2 maxApoE status
ApoB
mg/dL
Lp(a)
nmol/L
Glucose
mg/dL
HbA1c
% total Hb
Insulin
UIU/mL
VO2 max
mL/kg/min
ApoE status
Should be Empty:

Sample Submission

Current Longevity Interventions

Clinical History

Lab Measures