Medical Intake Form | Eternelle Health & Wellness

1

What is your first and last name?* This field is required.

First Name

Last Name

2

What is your phone number?

Please enter a valid phone number.

3

What is your email?* This field is required.

example@example.com

4

Just to be safe—do you have any of the following?Select all that apply. Skip to the next question if none apply.

Active cancer or history of cancer

Uncontrolled high blood pressure

Chronic migraines

Known allergy to NAD⁺ or any injectable/vitamin compound

Pregnancy or breastfeeding

5

Thanks for your honesty. Based on your health history, NAD⁺ may not be suitable for you.* This field is required.Please consult with your healthcare provider before taking it.

I understand

Go back

6

Which form of NAD⁺ are you planning to take?* This field is required.

Injectable (SubQ or IM)

Oral Troche

IV therapy under medical supervision

Not sure yet

7

Is there anything else we should know about your health or history before starting NAD⁺?Leave blank if none

8

9

All set! Just sign below to confirm and we’ll take it from here! Thank you. * This field is required.

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