What state do you live in?

We need this to match you with a licensed provider in your state.

Do any of these cardiovascular conditions apply to you?

NAD+ can affect blood pressure

Do you have a history of gout?

NAD+ precursors can elevate uric acid levels

Are you currently taking any PARP inhibitor cancer medications?

NAD+ directly interferes with PARP inhibitor treatment

What is your current height and weight?

Required by the prescribing physician.

What is your primary goal for this therapy?

This helps us personalize your treatment

Do you have any history of cancer?

This is critically important for peptide therapy safety

Do any of these apply to you?

These conditions may affect your eligibility

Are you taking any blood-thinning medications?

Have you used peptide therapy before?

Which peptides have you used, and did you have any adverse reactions?

Are you currently receiving peptides from another provider?

Are you pregnant, breastfeeding, or planning to become pregnant?

Are you a competitive athlete subject to drug testing?

All peptides on this list are prohibited by WADA

Are you currently taking any medications?

Please list all current medications and supplements

Do you have any allergies to injectable medications or peptides?

Please describe your allergies

Include any reactions to injectable medication excipients such as mannitol or benzyl alcohol

Anything else you'd like your doctor to know?

Share any additional information, questions, or concerns.

This is optional - only include what you think is important

Upload a photo of the front of your government-issued ID.

Driver's license, state ID, or passport. Required for prescriber identity verification.

Upload a selfie holding your ID.

Hold your ID up next to your face so your prescriber can confirm the ID is yours.

Off-Label / Investigational Compound Consent

This therapy uses a compounded peptide that is not FDA-approved for any indication. It is prescribed off-label based on your doctor's clinical judgment. By proceeding, you acknowledge that you understand this is not an FDA-approved treatment, that long-term safety data may be limited, and that you consent to off-label prescribing. Your doctor will review this with you on your video visit.