RENUVIA - NAD+ Intake Form

Unlock Your Vitality with our proven NAD+ Therapy

Join thousands who have transformed their energy, clarity, and overall wellness with our personalized anti-aging treatments.

✓ Boost Energy Levels

✓ Enhance Mental Clarity

✓ Improve Recovery

What would you love to achieve?

Select all that apply to personalize your experience.

More Energy

Wake up refreshed and maintain energy throughout the day

Mental Clarity

Sharper focus and improved cognitive performance

Better Recovery

Bounce back faster from workouts and daily stress

Healthy Aging

Feel younger and maintain vitality as you age

Better Sleep

Fall asleep easier and wake up more rested

Enhanced Mood

Feel more positive and emotionally balanced

How would you rate your overall health?

This helps us understand where you're starting from.

Excellent - I feel great most days Good - Generally healthy with minor issues Fair - Some health challenges Poor - Struggling with health issues

It feels like magic, but it's cellular science.

NAD+ LEVELS BY AGE

50%

NAD+ decline every 20 years

2-4 weeks

to feel increased energy

On average, NAD+ therapy patients report improved energy, better mental clarity, and enhanced cellular repair.

NAD+ supplementation offers these powerful anti-aging benefits – supporting your body's natural cellular processes for optimal health and vitality.

You're on the path to transformation!

Let's create your personalized treatment plan with a quick health assessment.

What's Next:

✓ Takes only 5-7 minutes to complete

🔒 Your information is 100% secure and confidential

✓ Reviewed by licensed physicians within 24 hours

✓ Personalized treatment recommendations

Let's start with some basic measurements

This helps us calculate the appropriate dosage for your treatment.

Feet

Inches

Weight (in lbs)

Date of Birth

You must be 18 or older to proceed

Tell us a bit about yourself

This ensures you're a good candidate for our treatments.

What was your sex assigned at birth?

Male Female

Your Current Symptoms

Let's understand what you're experiencing right now.

Are you currently experiencing any of the following?

Fatigue or Low Energy Memory Issues Difficulty Concentrating Depression or Anxiety Sleep Disorders Chronic Pain Other None of these apply to me

Your Treatment Goals

What would you like to achieve with this treatment?

What is your primary reason for requesting this medication?

General wellness Anti-Aging Antioxidant benefits Boost energy Brighten skin Detoxification Immune support Other

"My chronic fatigue is gone. For the first time in years, I'm not exhausted by 3pm, and I'm 52!"

Sarah enjoying an active lifestyle with renewed energy

Sarah regained her energy and vitality in just 3 months.

How will NAD+ work for you?

Energy &
Cellular
Health

Week 0

Week 4

Week 8

Week 12

Peak cellular

regeneration

• Week 1-4: Your NAD+ levels begin to restore

• Week 4-8: Energy production increases dramatically

• Week 9+: Your cells have become age-defying powerhouses

We address the root causes of cellular aging, so you get a long-term solution, not just another quick fix.

Your Treatment History

Let's review your past experiences and any health considerations.

Have you ever received anti-aging treatment before with metformin, glutathione or NAD?

Yes No

Did you experience any allergies or negative reactions to any of these?

Yes No

Please tell us more about what you used, when this was used, and what side effect you experienced

Do you have a known history of glucose-6-phosphate dehydrogenase (G6PD) deficiency, chronic kidney disease (CKD) or liver cirrhosis?

Yes No

Are you currently undergoing treatment for cancer, including chemotherapy or radiation therapy?

Yes No

"I play my best golf at 55. My tennis elbow and shoulder pain are gone!"

David reversed years of aging and became pain-free in just 4 months.

Visible Results in 8-12 Weeks

Sarah, 52

Before

After 12 weeks

Michael, 58

Before

After 12 weeks

✓ Reduced fine lines & wrinkles

✓ Improved skin elasticity

✓ Enhanced skin tone & texture

✓ Natural cellular rejuvenation

Your Medical Details

Please provide detailed information about your current health status.

Please identify all your current medical conditions

Please list all your current medications including dosages

Please list all of your known allergies

What other information or questions do you have for the doctor?

You're pre-approved for NAD+ therapy!

Complete your information below to lock in your personalized treatment plan and exclusive discount.

First Name

Last Name

Email Address

Phone Number

I understand that my information is never shared, is protected by HIPAA and agree to the terms and privacy policies and to be contacted as necessary by RenuviaRX and its medical partners and can opt-out at anytime.

What state will your medication be shipped to?

YOUR APPROVAL IS VALID FOR 15:00

Your NAD+ prescription plan approved!

★★★★★ 4.9 • 3.4K REVIEWS

NAD+ DECLINE

-47%

IMPROVEMENT
POTENTIAL

+93%

You'll get personalized care for your unique biology with prescribed NAD+ therapy, 1:1 physician guidance, and 24/7 Renuvia RX support.

Our Recommendation

NAD+ Levels

Expected NAD+ restoration timeline

Based on your intake form, we recommend NAD+ injection therapy. This is the most potent and effective treatment available.

You have a very high chance of success with NAD+ therapy

94.6%

VERY HIGH

The goals you will accomplish with your plan

♦ Boost energy levels by 50%+

🏆

♦ Cellular repair will make your skin look years younger

♦ Enhance mental clarity and cognitive function

Your plan

You will get everything you need to restore your NAD+ levels and reclaim your vitality.

What is included?

Effective NAD+ Therapy

1:1 Physician Guidance

Energy Boost Guarantee

+ 24/7 support and free shipping!

What Happens Next?

STEP 1

Physician Review

You're already pre-qualified. After checkout, a board-certified physician will review your information and begin the approval process.

STEP 2

Fast Prescription Approval

Most prescriptions are approved in less than 24 hours. If needed, same-day consultations with a licensed clinician are available — at no extra charge.

STEP 3

Medication Shipping

Once approved, your medication is prepared and shipped. You'll receive tracking info within 2 business days, and your prescription will be on its way.

STEP 4

Monthly Refills

Your NAD+ automatically ships every 30 days. We'll send email and text reminders 3 days before each shipment with tracking info. Manage your subscription anytime through your patient portal (skip, pause, or cancel with one click).

STEP 5

Unlimited Support

Have questions about your progress, side effects, or dosage? You'll have unlimited, 24/7 access to our care team and licensed clinicians — whenever you need us.

Your approval is reserved for 15:00

Save Over $100 Instantly

No contracts, cancel anytime without speaking to anyone.

24/7 Support • unlimited doctor visits • medication all included.

IN STOCK

RenuviaRX NAD+ Therapy
1200mg (6mL)

★★★★★

2.1K REVIEWS

Prescribed for only $179

$299

✓ Premium NAD+ injections for anti-aging therapy

✓ Save $120 instantly on your first month

✓ PRICE INCLUDES: doctor consult, unlimited 1:1 medical support, written prescription + 4 weeks of medicine and free shipping

✓ Most popular NAD+ therapy program

✓ Prescribed by world-class, US-based, board-certified clinicians

✓ Free priority overnight shipping

✓ Send a message to your doctor 24/7

What Our Patients Say

Michael R., 52

★★★★★

Verified

"After 3 months on NAD+ therapy, my energy levels are through the roof. I feel like I'm in my 30s again. No more afternoon crashes, and my mental clarity has improved dramatically."

Jennifer S., 45

★★★★★

Verified

"As a marathon runner, recovery was becoming harder with age. NAD+ injections have been a game-changer. I recover faster, sleep better, and my endurance has noticeably improved."

David L., 58

★★★★★

Verified

"Skeptical at first, but the results speak for themselves. Better mood, clearer skin, and more stamina throughout the day. My wife started the program after seeing my transformation."

Unlock Your Vitality with our proven NAD+ Therapy

What would you love to achieve?

How would you rate your overall health?

It feels like magic, but it's cellular science.

You're on the path to transformation!

What's Next:

Let's start with some basic measurements

Tell us a bit about yourself

Pregnancy Consent

Your Current Symptoms

Your Treatment Goals

"My chronic fatigue is gone. For the first time in years, I'm not exhausted by 3pm, and I'm 52!"

How will NAD+ work for you?

Your Treatment History

"I play my best golf at 55. My tennis elbow and shoulder pain are gone!"

Visible Results in 8-12 Weeks

Sarah, 52

Michael, 58

Your Medical Details

You're pre-approved for NAD+ therapy!

Informed Consent Statement

Truthfulness Attestation

Your NAD+ prescription plan approved!

Our Recommendation

The goals you will accomplish with your plan

Your plan

What is included?

Effective NAD+ Therapy

1:1 Physician Guidance

Energy Boost Guarantee

What Happens Next?

Physician Review

Fast Prescription Approval

Medication Shipping

Monthly Refills

Unlimited Support

Save Over $100 Instantly

RenuviaRX NAD+ Therapy1200mg (6mL)

What Our Patients Say

RenuviaRX NAD+ Therapy
1200mg (6mL)