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Nicotinamide Adenine Dinucleotide (NAD+) Intramuscular (IM) Therapy Consent Form
Please read and agree to each statement.
I have informed the provider of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed the provider of my medical history.
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Agree
Allergies:
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Please Select
No known allergies
See List of Allergies
List of Allergies
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I understand that NAD+ (Nicotinamide Adenine Dinucleotide) may be administered as part of Intramuscular (IM) therapy.
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Agree
I acknowledge and agree to the following: NAD+ is contraindicated in individuals with a history of cancer in the last 5 years or with any current cancer diagnosis. Caution is advised for individuals with cardiac conditions or those taking cardiac medications.
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Agree
Side effects may include chest tightness, heaviness, and headaches. If headaches occur, I may take a baby aspirin 30 minutes prior to injection to reduce symptoms.
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Agree
Today's Date
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Year
Date
Date of Birth
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Month
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Year
Date
Name
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First Name
Last Name
Signature - Your signature signifies your consents to the use and disclosure of your PHI by our office during treatment, billing, reimbursement, and medical office operations. You agree and consent that your PHI may be communicated to you via telephone or email (encrypted or unencrypted).
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