GLP-1, NAD+, Glutathione, Sermorelin, and others Intake Form

1
Basic Information
Full Name
Please enter your email
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Date of Birth
2
Home Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
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Denmark
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
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India
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Iran
Iraq
Ireland
Israel
Italy
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Japan
Jersey
Jordan
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Kenya
Kiribati
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Laos
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Madagascar
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Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Basic Health Information * This field is required.
4
Continued* This field is required.
5
If yes, you may not be eligible for GLP-1 therapy.
6
Have you or a direct family member been diagnosed with medullary thyroid cancer or Multiple Endocrine Neoplasia type 2 (MEN2)?* This field is required.
Yes
No
7
Have you ever had pancreatitis?* This field is required.
Yes
No
8
When did it occur and was it resolved?
9
Do you have gastroparesis or a severe GI motility disorder?* This field is required.
Yes
No
10
Have you had gastric bypass, sleeve gastrectomy, or other bariatric surgery?* This field is required.
Yes
No
11
Please specify the procedure.
12
Do you have diabetes?* This field is required.
Yes
No
13
Current diabetes medications
Insulin
Metformin
Sulfonylurea
SGLT-2 inhibitor
Other
14
If taking insulin, specify type and dose
15
Have you experienced frequent low blood sugar (hypoglycemia) episodes?* This field is required.
Yes
No
16
How often?
17
Have you previously used a GLP-1 medication such as Ozempic, Wegovy, or Mounjaro?* This field is required.
Yes
No
18
Which medication and did you have any adverse reactions?
19
What is your primary goal with GLP-1 therapy?* This field is required.
Weight loss
Blood sugar management
Metabolic health
Other
20
Which GLP-1 medication are you requesting?* This field is required.
Tirzepatide
Semaglutide
Provider recommendation
21
Are you interested in microdosing?* This field is required.
Yes
No
Not sure
22
Have you ever had medullary thyroid cancer or MEN2?* This field is required.
Yes
No
Unsure
23
Have you ever had pancreatitis?* This field is required.
Yes
No
24
If yes, when did it occur?
25
If yes, was the cause identified and treated?
Yes
No
26
Do you have any of the following conditions?* This field is required.
Gastroparesis
Previous gastric/bariatric surgery
Active gallbladder disease
Chronic nausea or vomiting
None of the above
27
If you selected previous gastric/bariatric surgery, please specify the type of surgery
28
If you have diabetes, when was your last eye exam?
Within past 12 months
More than 12 months ago
Never
Not applicable
29
Do you have diabetic retinopathy?
Yes
No
Unsure
30
Which diabetes medications are you currently taking?
Insulin
Sulfonylureas
DPP-4 inhibitors
Metformin
None
Other
31
Do you have diabetic retinopathy?
Yes
No
Unknown
32
Date of last eye exam
33
If taking insulin, specify type and dose
34
If selected Other, please specify
35
Have you experienced frequent low blood sugar episodes?* This field is required.
Yes
No
36
If yes, how often?
37
Do you have a history of kidney disease or kidney stones?* This field is required.
Yes
No
38
If yes, please describe your kidney history.
39
Have you had an allergic reaction to a GLP-1 medication such as semaglutide or tirzepatide?* This field is required.
Yes
No
40
If yes, please describe the reaction
41
What are your goals for starting this medication?* This field is required.
Improve blood sugar control
Weight loss
Reduce cardiovascular risk
Other
42
If other, please specify
43
Which GLP-1 are you requesting?
Semaglutide (Ozempic)
Semaglutide (Wegovy)
Semaglutide (Rybelsus)
Liraglutide (Victoza)
Liraglutide (Saxenda)
Dulaglutide (Trulicity)
Exenatide (Byetta)
Exenatide ER (Bydureon BCise)
Lixisenatide (Adlyxin)
Orforglipron (Foundayo)
Tirzepatide
None
44
Do you want it micro dosed or not?
Yes
No
45
Are you requesting nicotinamide riboside (NR), nicotinamide mononucleotide (NMN), or oral liposomal Glutathione?
Nicotinamide riboside (NR)
Nicotinamide mononucleotide (NMN)
Oral liposomal Glutathione
Semorelin
Ipamorelin
CJC-1257
None
46
Which of the following are you interested in or currently using?* This field is required.
GLP-1 / Weight Loss Medications (Tirzepatide, Semaglutide)
NAD+ (IV or Injection)
Glutathione (IV or Injection)
Peptides (Sermorelin, Bremelanotide/PT-141)
Vitamin / Amino Acid Infusions (GaleB, MIC+B12, Glutamine, Arginine, L-Carnitine)
47
Are you pregnant, planning to become pregnant, or breastfeeding?
Yes
No
48
Do you have any known drug allergies?
Yes
No
49
Are you currently taking any prescription medications?
Yes
No
50
Please list all current medications.
51
Do you have any personal history of the following?
Active or prior cancer
Heart disease
Kidney disease
Liver disease
Autoimmune condition
Seizures or epilepsy
Stroke or TIA
None of the above
52
Do you have any active infection or fever today?
Yes
No
53
Do you have a history of severe allergic reaction or anaphylaxis?
Yes
No
54
Have you had medullary thyroid cancer or MEN2?* This field is required.
Yes
No
55
If yes, this medication is not appropriate for you.
56
Have you ever had pancreatitis?* This field is required.
Yes
No
57
When did the pancreatitis occur?
Date
Month
Day
Year
58
Was the cause identified and treated?
Yes
No
59
Do you have diabetes?
Yes
No
60
Which diabetes medications are you currently taking?
Insulin
Sulfonylureas
DPP-4 inhibitors
Metformin
Other
None
Other
61
If taking insulin, specify type and dose
62
When was your last eye exam?
Within past 12 months
More than 12 months ago
Never
Not applicable
63
Do you have diabetic retinopathy?
Yes
No
Unsure
64
Current medication list
Prescription medications
Over-the-counter medications
Supplements
None
Other
65
Do you take any medications that affect metabolism or blood sugar?
Metformin
GLP-1 medications
Insulin
Steroids
None
Other
66
Do you have any medication sensitivities or allergies?
Yes
No
67
Please describe any sensitivities or allergies
68
Have you ever had seizures?
Yes
No
69
Do you have a history of thyroid disease?
Yes
No
70
Do you get cold sores or herpes outbreaks?
Yes
No
71
Pharmacy Name and Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
72
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73
Do you have a history of cancer or are you currently undergoing chemotherapy or radiation?
Yes
No
74
Do you have a history of kidney disease?
Yes
No
75
Do you have a history of nausea or sensitivity to IV infusions?
Yes
No
76
Are you currently taking niacin supplements or medications for alcohol dependency?
Yes
No
77
If Yes: describe
78
Preferred NAD+ delivery method
IV infusion
Subcutaneous injection
Oral/Liposomal NAD+
Not sure
79
Do you have a known sensitivity to sulfur-containing compounds?
Yes
No
80
Do you have asthma or reactive airway disease?
Yes
No
81
Do you have a history of kidney or liver disease?
Yes
No
82
Are you currently taking any blood thinners or anticoagulants?
Yes
No
83
Preferred glutathione form
IV push
IV infusion
Oral/Liposomal
Not sure
84
Do you have a history of pituitary tumors or pituitary dysfunction?
Yes
No
85
Do you have a history of active cancer or are you currently in remission?
Yes
No
86
Do you have sleep apnea?
Yes
No
87
Are you interested in Sermorelin?
Yes
No
Tell me more
88
Do you have a history of high blood pressure or cardiovascular disease?
Yes
No
89
Are you currently taking a PDE5 inhibitor such as sildenafil (Viagra) or tadalafil (Cialis)?
Yes
No
90
Do you have a history of nausea with medications?
Yes
No
91
Are you interested in Bremelanotide (PT-141)?
Yes
No
Tell me more
92
Do you have a history of kidney disease or kidney stones?* This field is required.
Yes
No
93
Do you have a G6PD deficiency?* This field is required.
Yes
No
Unknown
94
Do you have a history of gout?* This field is required.
Yes
No
95
Are you currently taking any B-vitamin supplements?* This field is required.
Yes
No
96
If Yes: list them
97
Do you have a history of herpes simplex (cold sores or genital herpes)?* This field is required.
Yes
No
98
Do you have a history of seizures or thyroid disease?* This field is required.
Yes
No
99
Which infusions are you interested in?* This field is required.
GaleB + Methylfolate (Methyl-B12/B1/B2/B3/B5/B6/Methylfolate)
MIC+B12 25mg/mL
MIC+B12 50mg/mL
MIC+B12 67mg/mL
Glutamine
Arginine
L-Carnitine 25mg/mL
L-Carnitine 100mg/mL
L-Carnitine 250mg/mL
Provider recommendation
100
Primary health goals* This field is required.
Weight loss
Increased energy and vitality
Anti-aging
Athletic performance and recovery
Metabolic health
Sexual wellness
Immune support
Hormone optimization
Mental clarity and focus
Other
101
If Other, please describe
102
Current activity level* This field is required.
Sedentary
Lightly active (1-2x/week)
Moderately active (3-4x/week)
Very active (5+x/week)
Competitive athlete
103
Do you smoke or use tobacco products?* This field is required.
Yes
No
Former smoker
104
How often do you consume alcohol?* This field is required.
Never
Occasionally (social)
Regularly (weekly)
Daily
105
Any additional health information or concerns you would like the provider to know?
106
I confirm that all information provided in this form is accurate and complete to the best of my knowledge.* This field is required.
I confirm
107
I understand this intake form does not constitute a medical prescription. A licensed provider will review my information before any treatment is recommended.* This field is required.
I understand
108
Signature Date* This field is required.
Date
Month
Day
Year
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