NAD+ Consent Form

Form
NAD+ MEDICAL INTAKE FORM
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Type a question
Are you male or female?
What are you hoping will change with NAD+?
Are you currently breastfeeding or pregnant?
Do you currently have cancer or have had cancer in the past?
Is there any other health concerns you would like to share with us?
Nicotinamide Adenine Dinucleotide (NAD) Informed Consent

NAD(Nicotinamide Adenine Dinucleotide) occurs naturally in the body and helps to support healthy mitochondrial function of the cells. Mitochondria produce energy for the cells, and by extension are critical for total body energy. One of theories of aging is that the mitochondria degrade as we get older. Its been theorized that supplementing NAD may affect normal aging in a favorable manner by improving mental clarity,, improving concentration and memory, enhancing energy, reducing fatigure, and countering the effects of Neurodegeneration, including Alzheimer’s disease.
Risks: mild to moderate side effects, such as nausea, fatigue, headaches, headache or chest tightness, diarrhea, stomach discomfort and indigestion.
I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment.
I understand that I will self administer a Sub-Q injection or I will schedule an appointment with New You Wellness for the nurse to administer my medication. I agree to not share my medication with any other individual.
I understand that if I am feeling sick in any way that I should abstain from using NAD until I have fully recovered.
By signing this consent, I acknowledge reading the informed consent and agree to the treatment and associated risks. I release New You Weight Loss & Wellness Center and it’s affiliates from all claims related to NAD injections. I give consent for this and all future NAD infusions.
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Form

NAD+ MEDICAL INTAKE FORM