mynad Intake & Order Form

Intake & Order Form
The first step is determining if mynad’s longevity formulations are right for you. Answer these 3 questions to check your eligibility.
YesNo
YesNo
YesNo
You are currently ineligible for mynad products.

Your responses suggest a mynad solution may not be suitable due to health, medication or supplement-related factors. However, this doesn’t mean we can’t help - it may simply mean a more tailored approach is required. We recommend speaking with one of our compounding pharmacists to better understand your needs and determine if a custom formulation can be made for you. Please email info@mynad.com.au with your details.
Personal Information
Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Phone Number (This is the number the Pharmacist will use to call you)*
Please enter a valid phone number.
Email
example@example.com
Delivery Address*
Include street name and house/unit number
Suburb*
State*
Postcode*
Smoking Habits
YesNo
1-56-1011-1516-20More than 20
Less than 1 year1-5 years6-10 yearsMore than 10 years
Dietary Habits
No specific dietVegetarianVeganGluten-FreePescatarianPaleoKetoOther
Exercise Habits
YesNo
1-2 times3-4 times5-7 times
CardioStrength trainingFlexibility exercisesMixed
Family Medical History
Heart diseaseDiabetesCancerHypertensionMental health disordersNone
Previous Treatments
YesNo
Very EffectiveEffectiveSomewhat EffectiveNot Effective
YesNo
MedicationLifestyle ChangesDietary AdjustmentsPhysical TherapyOther
Your Medication History
YesNo
PainkillersAntibioticsAntidepressants/Anti-anxietyHormone Replacement Therapy (HRT)AntihypertensivesOther
YesNo
Side effectsIneffectiveDoctor's recommendationCondition improvedSwitched to a different medicationOther
YesNo
RashNauseaHeadacheDizzinessFatigueOther
YesNo
Select Your Health Objective
Rapid NAD+Anti-ageingEnergy SupportCognitive EnhancementSkin Vitality
Anti-ageingEnergy SupportCognitive EnhancementSkin Vitality
Rapid NAD+ Questions
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
✅ Rapid NAD+ (30 x Lozenges) is your approved product and will be custom blended by the compounding pharmacist based on the information you have provided.

Complete any remaining sections and scroll to the bottom to complete checkout.
Energy Support Questions
YesNo
YesNo
Yes – they vary a lotNo – they’re generally stable
Yes – regularlyOccasionallyNo
Yes – every dayOccasionallyNo
Yes – one or more of theseNoNot sure
YesNo
✅ Energy (30 x Capsules) is your approved product and will be custom blended by the compounding pharmacist based on the information you have provided.

Complete any remaining sections and scroll to the bottom to complete checkout.
Cognitive Enhancement Questions
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
✅ Cognitive Enhancement (30 x Capsules) is your approved product and will be custom blended by the compounding pharmacist based on the information you have provided.

Complete any remaining sections and scroll to the bottom to complete checkout.
Anti-ageing Questions
YesNo
YesNo
YesNo
YesNoNot Sure
YesNoNot Sure
YesNoNot Sure
✅ Anti-ageing (30 x Capsules) is your approved product and will be custom blended by the compounding pharmacist based on the information you have provided.

Complete any remaining sections and scroll to the bottom to complete checkout.
Skin Vitality Questions
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
✅ Skin Vitality (30 x Capsules) is your approved product and will be custom blended by the compounding pharmacist based on the information you have provided.

Complete any remaining sections and scroll to the bottom to complete checkout.
Consent & Legal Agreements
YesNo
Any additional comments or questions?
Summary of Terms, Privacy and Purchase Conditions*
Checkout

Most people begin noticing effects after 4–6 weeks. We recommend continuing your personalised formulation for at least 3 months to allow time for meaningful results. This is a flexible monthly subscription which you can cancel at any time. You’ll receive an email reminder before each billing cycle with clear cancellation instructions.
Rapid NAD+
Price - Rapid NAD+
Energy Support
Energy Support
Price - Energy
Cognitive Enhancement
Cognitive Enhancement
Price - Cognitive Enhancement
Anti-ageing
Anti-ageing
Price - Anti-ageing
Skin Vitality
Skin Vitality
Price - Skin Vitality
Cart Account

Terms and conditions Store policy Privacy policy
Should be Empty:

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Enter coupon

Intake & Order Form

The first step is determining if mynad’s longevity formulations are right for you. Answer these 3 questions to check your eligibility.

You are currently ineligible for mynad products.

Personal Information

Smoking Habits

Dietary Habits

Exercise Habits

Family Medical History

Previous Treatments

Your Medication History

Select Your Health Objective

Rapid NAD+ Questions

Energy Support Questions

Cognitive Enhancement Questions

Anti-ageing Questions

Skin Vitality Questions

Consent & Legal Agreements

Checkout