NAD Self-Injection Order Form

Full Name*

First NameLast Name

Email Address*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Delivery Address*

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Date of Birth (needed to send prescription)*

Date

Please upload a picture of your ID (Drivers license, passport, state ID)*

I am located in one of the following states: NY, NJ, CT, MA, TX, FL, AZ, NM, IL, WI, UT, VA*

YesNo (Note: Choosing "NO" disqualifies you from receiving prescription NAD)

I confirm I am 18 years old or older.*

YesNo (Note: Being under 18 years of age disqualifies you from receiving NAD)

Do any of the below apply to you? Select "None of the above" if none do. *

I understand that I am responsible for following the injection instructions provided and that improper injection technique my result in pain, bruising, infection, or other complications. I understand that I must use sterile technique, never reuse needles, and properly dispose of sharps. *

Have you ever self-administered an injection before (insulin, GLP-1, Testosterone)?*

YesNo

Informed Consent — I understand that injectable NAD+ is a compounded medication and is NOT FDA-approved. I understand that results vary and no specific outcome has been guaranteed to me. I understand the potential side effects including but not limited to: redness, bruising, or soreness at the injection site; nausea; flushing; headache; and in rare cases, allergic reaction. I understand that NAD+ therapy is elective and not medically necessary. I agree to discontinue use and contact Dr. Mahjoubi immediately if I experience any adverse reaction including signs of infection (increasing redness, warmth, swelling, pus), chest pain, difficulty breathing, or severe allergic reaction. I confirm that all medical information I have provided is accurate and complete, and I understand that withholding or providing inaccurate information may result in serious harm for which I bear responsibility. 7. Telehealth Consent I consent to receiving medical evaluation and treatment via telemedicine. I understand that this consultation does not involve a physical examination and that the prescribing physician is relying on the information I provide. I understand that telemedicine has limitations and that I should seek in-person emergency care if I experience a medical emergency. 8. HIPAA Acknowledgment: I acknowledge that my health information will be handled in accordance with HIPAA privacy regulations. 9. Financial Terms & No-Refund Policy: I understand that the fee of $200 per kit covers the physician evaluation, prescription, and medication with supplies. I understand that compounded medications cannot be returned or refunded once shipped. I accept financial responsibility for all charges. 10. I acknowledge that I am voluntarily choosing to participate in NAD+ therapy. I understand the risks, benefits, and alternatives, including the option of not proceeding. I accept full responsibility for my decision to self-administer injectable NAD+ and agree to hold Dr. Farzad David Mahjoubi, MD, and NutraBrain Clinic Inc. DBA Dr. David Wellness harmless from any adverse outcome resulting from my use of this product, except in cases of gross negligence. *

Please list all medical conditions you currently have. If none please write "none." *

List all current prescription medications without dosages. If none please write "none." *

My Products

NAD+ 200 mg/mL

6 mL

$225.00 Quantity

Total

$0.00

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