Elevate Ketamine - Medical History & Contact for NAD+ Delivery

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Date of Birth*

Date

Gender

FemaleMaleOther

Driver's License #*

Driver License State of Issue*

Street Address*

City*

State*

Zip Code*

How did you find out about Elevate Ketamine?

Emergency Contact Full Name*

Primary Care Provider*

Primary Care Provider Phone Number

Please enter a valid phone number.

Mental Health Care Provider

Mental Health Provider Phone Number

Please enter a valid phone number.

Height*

Feet (') and Inches(")

Weight*

in lbs

Please list any allergies (food/medication/supplement) you have, if any.*

Please describe allergic reactions, if any.

Do you currently take any medications? Please list the medication name, dosage, and reason for taking.*

I am currently compliant with all medications prescribed by my mental health provider.*

YesNoNot applicable

If you answered "No" above, please give some detail.

Have you had any previous surgeries or procedures?*

Have you experienced any decrease in sex drive or libido?*

Do you have any chronic medical conditions?*

YesNo

Additional information about your chronic medical condition.

How many hours a week do you exercise?

Have you had any problems sleeping?*

Do you have a history of hypoglycemia?*

YesNo

Do you have any history of thyroid cancer in your family?*

YesNo

Have you ever had pancreatitis?*

YesNo

Do you have any renal/kidney issues?*

YesNo

Do you have any of these conditions? Check more than one if applicable.

NEUROLOGIC/MOOD

METABOLIC/ENDOCRINE

RESPIRATORY

GU/GI

CARDIOVASCULAR

PAIN

INFECTIOUS

HEMATOLOGY/ONCOLOGY

SUBSTANCES

OTHER

Do any of the following apply to you? Semaglutide is safe and effective with many pre-existing conditions, with the exception of the following:

I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as not being treated. Those risks and potential complications have been explained to me. I have not been promised or guaranteed any specific benefit from the administration of these therapies and no warranty or guarantee has been made regarding the results of treatment. I agree to proceed with treatment and to comply with recommended dosages. I agree to comply with requests for ongoing testing to assure proper monitoring of my treatments that may include laboratory evaluation of all aforementioned hormone levels or other diagnostic testing by an Elevate Ketamine provider, my primary care physician, or other specialist. I agree to see my primary care physician, gynecologist, or other practitioner for regular monitoring and for preventative measures that may include but are not limited to complete physicals, rectal examinations and/or colonoscopy, EKG, mammograms, pelvic/breast exams, pap smears, prostate exams, PSA levels, etc. at least on a yearly basis. I agree to immediately report to my physician any adverse reaction or problem that might be related to my therapy. I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as to not being treated. Those risks and potential complications have been explained to me and I agree that I have received information regarding those risks, potential complications and benefits, and the nature of and other hormone treatments and have had all my questions answered. Furthermore, I have not been promised or guaranteed any specific benefit from the administration of hormone therapy. I certify this form has been fully explained to me, that I have read it or have had it read to me and that I understand its contents. I agree not to undergo any treatments unless I fully understand the treatment and have discussed possible risks and benefits. I agree to the therapy described above. I have been educated on the benefits, risks, and possible adverse reactions associated with hormone replacement therapy. I agree all the above health information submitted on the questionnaire is complete and accurate.

Please confirm*

I have read and understand the above statement

Email*

example@example.com

Signature*

Medical History & Contact Information

Personal Information

Address

Medical Information

Do you have any of the following conditions?

The following questions are for those ordering Semaglutide or Tirzepatide.

Please read and confirm you understand the Statement of Patient:

All submissions reviewed by Dr. Angelo Asheh MD.

Once the form is submitted, it will be reviewed by a physician. If we need any more information we will contact you.