IM NAD+ Medical Intake Form

IM NAD+ Medical Intake 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 Code
Date of Birth (needed to send prescription)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I confirm I am 18 years old or older.
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)?
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."
Should be Empty: