H&P CERTIFICATION — NAD+ INJECTIONS

KosherMedications.com
Health & Physical (H&P) Self-Assessment Declaration

By completing my purchase of NAD+ Injections through KosherMedications.com, I certify under penalty of perjury that the following statements are true and correct to the best of my knowledge and belief. I understand that a licensed healthcare provider will rely upon this information when determining whether a prescription or compounded preparation is clinically appropriate.

General Information

I affirm that I:

• am 18 years or older, completing this assessment for myself, voluntarily, and providing accurate identifying information including my full name, address, and contact details.

• will use this service and any prescribed medication solely for myself and will not share or distribute it to others.

• understand that NAD+ Injections may be dispensed only if medically appropriate, based on my self-reported information and clinical review.

• acknowledge that a licensed healthcare provider may contact me for clarification or additional information before approval.

• have reviewed and accepted KosherMedications.com’s Terms of Service and Consent to Telehealth, which govern this interaction and any related care.

Consent to Telehealth

I understand and acknowledge that:

• This service uses an asynchronous telehealth model, allowing me to provide medical information online for review by a licensed provider.

• A valid provider-patient relationship is created for this encounter and may include follow-up communication if needed.

• Telehealth is a supplemental mode of care and does not replace in-person evaluation or ongoing monitoring by my primary provider.

• Because of the nature of telemedicine, the reviewing provider cannot continuously monitor my condition, lab results, or side effects. I accept these limitations and associated risks.

• All personal and medical information will be transmitted and stored securely in accordance with HIPAA and applicable privacy regulations.

• In the event of a medical emergency, I will call 911 or seek immediate in-person emergency care and will not rely on telehealth communication for urgent or life-threatening issues.

Clinical Information Related to NAD+ Injections

I confirm that I:

• understand that NAD+ (nicotinamide adenine dinucleotide) is used to support cellular energy production, metabolic function, and mitochondrial health, but is not FDA-approved for any specific medical indication.

• understand that NAD+ Injections may cause side effects such as flushing, warmth, nausea, abdominal discomfort, lightheadedness, rapid heartbeat, or injection site irritation, especially if administered too quickly.

• will stop treatment and seek medical attention if I experience chest pain, severe dizziness, difficulty breathing, fainting, or allergic reactions.

• have not experienced hypersensitivity or allergic reactions to NAD+, niacin derivatives, or any component of the formulation.

• do not have uncontrolled chronic conditions that may increase risk, including:

  • active liver disease

  • severe kidney impairment

  • uncontrolled diabetes

  • significant cardiovascular disease

  • active infection or fever

  • recent major surgery

• am not pregnant or breastfeeding, and will notify a healthcare provider immediately if that changes before or during treatment.

• do not consume excessive alcohol, which may increase risk of metabolic complications.

• understand that NAD+ may interact with certain medications, including:

  • medications affecting blood pressure or heart rate

  • medications impacting mitochondrial or metabolic pathways

  • niacin, vitamin B3 or B-complex supplements

  • medications affecting glucose regulation

• will inform my reviewing provider of all medications, supplements, and herbal products I am currently taking.

• understand that dosing schedules may vary and that administration should be performed only as directed by a licensed provider or trained clinician.

• understand that NAD+ should be administered carefully to avoid rapid infusion or injection reactions.

Health Status & Representations

I attest that I:

• am in generally good health, apart from the condition or purpose for which I am seeking NAD+ Injections.

• have truthfully disclosed all relevant medical history, conditions, medications, and allergies.

• understand that my submission may be reviewed by a licensed provider, who may request additional information before issuing a prescription or approving treatment.

• confirm that this certification represents all relevant information I would disclose during an in-person medical visit.

General Information About Prescription or Compounded Medications

I understand that:

• This certification does not list every possible precaution, risk, or side effect related to NAD+ Injections.

• NAD+ formulations may be compounded, and compounded medications are not reviewed or approved by the FDA but are prepared according to U.S. compounding standards.

• Additional information regarding NAD+ and drug interactions can be found at:

  • www.fda.gov

  • www.drugs.com/drug_interactions.html

• I will review any Medication Guide or compounding instructions provided with my prescription and consult with a healthcare provider if I have further questions.

Pharmacy & Fulfillment Information

I acknowledge that:

• KosherMedications.com partners with licensed pharmacies and compounding facilities to dispense medications in compliance with state and federal laws.

• Reviewing providers act independently and are not employees of the pharmacy.

• I consent to receive education materials, refill notices, and updates electronically.

• I am responsible for reviewing this certification and contacting support@koshermedications.com with any concerns before starting treatment.

Emergency Disclaimer

I understand that KosherMedications.com and its affiliated providers do not provide emergency medical services.
In the event of an emergency or severe reaction, I will call 911 or seek immediate in-person care at the nearest emergency department.

By completing my purchase, I affirm that all statements above are true, accurate, and complete to the best of my knowledge.