Step 3 of 5 — Medical Assessment

GLP-1 intake
questionnaire

Your physician will review these answers before approving your prescription. Please answer honestly and completely.

Clarity

Semaglutide+ · GLP-1

Question 1

Have you ever had, or do you currently have, any of the following?

Select all that apply.

Question 2

Do you have any known allergies to any of the following?

Question 3

Have you had any of the following surgical procedures?

Question 4

Have you taken a GLP-1 weight loss medication in the last month?

Question 5

Are you currently taking a non-GLP-1 weight loss medication?

Question 6

Would you like to increase, maintain, or decrease your current GLP-1 dose?

Final titration will be determined by your physician.

Question 7

Please list all medications and supplements you are currently taking.

Question 8

What is your goal weight (lbs)?

Question 9

Which side effects are you most concerned about?

Select all that apply. This helps your physician personalize your compound.

Question 10

I have read and understood the GLP-1 safety information and consent to treatment.

Question 11

I understand and acknowledge the following regarding my compounded medication and multi-dose vial.

I acknowledge that my medication will be dispensed in a multi-dose vial to allow for physician-directed, personalized dose titration. I understand that my dose will be customized under my Verda physician's supervision and that I am responsible for following proper injection technique and dosing instructions as provided.

Question 12

Please type your full legal name in lieu of a signature.

Question 13 (Optional)

Is there anything else you'd like your physician to know?

Health history, weight loss journey, or goals. This is optional.

Your information is encrypted and protected under HIPAA.

Step 3 of 5 — Medical Assessment

NAD+ program
intake form

Your physician will review these answers before approving your NAD+ protocol.

Luminary

NAD+ · Injectable · Longevity

Question 1

What is the primary reason you are seeking NAD+ therapy?

Select all that apply.

Question 2

Have you used NAD+ therapy in the past?

Question 3

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

Question 4

Do you currently have, or have you ever been diagnosed with, any of the following?

Select all that apply.

Psychiatric conditions are not necessarily contraindications to NAD+ therapy and may benefit from it. Your physician would like to be aware of these conditions before prescribing.

Question 5

Are you currently taking any medications that may interact with NAD+?

This includes chemotherapy drugs, immunosuppressants, and medications that affect cellular metabolism.

Question 6

Do you have a known allergy to NAD+ or any of its components?

NAD+ components include NAD, NADH, ENADA, and NAD+.

Question 7

Do you have any known allergies to any of the following?

Question 8

Are you currently taking any prescription medications, therapies, or supplements?

Question 9

I have read and understood the NAD+ therapy information and consent to treatment.

Question 10

Please type your full legal name in lieu of a signature.

Question 11 (Optional)

Is there anything else you'd like your physician to know?

Your information is encrypted and protected under HIPAA.

Step 3 of 5 — Medical Assessment

Microdose program
intake form

Your physician will review these answers before approving your microdose longevity protocol.

Calibrate

Tirzepatide Microdose · Longevity

Question 1

What is the primary reason you are seeking GLP-1 longevity microdose therapy?

Select all that apply.

Question 2

Have you experienced any specific symptoms of aging that you believe microdosing could help with?

Question 3

Have you discussed GLP-1 longevity microdose treatment with your primary care physician?

Question 4

Have you taken a GLP-1 medication in the last month?

Question 5

When was the last time you had an in-person medical evaluation?

Question 6

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

Question 7

Have you ever had, or do you currently have, any of the following?

Question 8

Do you have any known allergies to any of the following?

Question 9

Please list all medications, therapies, and supplements you are currently taking.

Question 10

Are you aware that GLP-1 microdosing for longevity is an off-label use, and that scientific research on its long-term benefits is still in early stages?

Question 11

I have read and understood the GLP-1 microdose therapy information and consent to treatment.

Question 12

I understand and acknowledge my compounded medication will be dispensed in a multi-dose vial for physician-directed titration.

Question 13

Please type your full legal name in lieu of a signature.

Question 14 (Optional)

Is there anything else you'd like your physician to know?

Your information is encrypted and protected under HIPAA.

GLP-1 intakequestionnaire

NAD+ programintake form

Microdose programintake form

GLP-1 intake
questionnaire

NAD+ program
intake form

Microdose program
intake form