Longevity & Wellness Intake

Step 1 of 6

Longevity & Wellness Intake

Lavena Health offers a comprehensive longevity and cellular optimization program. Please complete this intake so your physician can design the right protocol for you.

Personal Details

First Name *

Last Name *

Date of Birth *

Biological Sex *

State *

Email *

Phone *

Street Address *

City *

ZIP Code *

Height

Weight (lbs)

BMI (auto)

How did you hear about us?

If referred by someone, please share their name (optional)

Step 2 of 6

Symptom Assessment

Rate each symptom over the past 4 weeks. 0 = None | 1–2 = Mild | 3–4 = Moderate | 5 = Severe

Energy & Cognition

Chronic fatigue / low energy

Persistent tiredness not improved by rest

Brain fog / poor concentration

Memory issues / forgetfulness

Depression / low mood

Poor sleep quality / insomnia

Slow recovery after exercise or illness

Oxidative stress / inflammation symptoms

Joint pain, frequent illness, slow wound healing, skin aging

Metabolic symptoms

Weight gain, insulin resistance, blood sugar issues, high cholesterol

How long have you been experiencing these symptoms?

Any other symptoms or concerns?

Your Longevity & Wellness Goals

Select all that apply. Your physician will use these to shape your protocol.

More energy and stamina in daily life

Better cognitive function, focus, and memory

Improved sleep quality and recovery

Slow physical aging and extend healthspan

Improve metabolic health / insulin sensitivity

Enhance athletic performance and recovery

Reduce oxidative stress and inflammation

Improve skin quality and appearance

Support addiction recovery

Anything else you want your physician to know about your goals?

Step 3 of 6

Treatment Interests

Select all therapies you are interested in. Your physician will review and recommend the most appropriate protocol based on your symptoms and labs.

NAD+ Therapy

NAD+ (Nicotinamide Adenine Dinucleotide) is a coenzyme essential for cellular energy production and DNA repair. Levels decline ~50% by age 60. Replacement dramatically improves energy, cognition, and cellular aging markers.

SubQ Injection

NAD+ SubQ Injection

100–500mg self-administered at home. Avoids GI side effects of oral precursors and delivers NAD+ directly. Ideal for ongoing maintenance and energy/cognition support.

Oral

NAD+ Precursors (NMN / NR)

Nicotinamide Mononucleotide (NMN) or Nicotinamide Riboside (NR) — oral NAD+ precursors for daily maintenance. Best combined with resveratrol or pterostilbene.

Have you received NAD+ therapy before?

Glutathione Therapy

Glutathione is the body's master antioxidant — produced in the liver and found in every cell. Depletion is associated with aging, chronic illness, toxic exposure, and oxidative stress. Subcutaneous delivery bypasses oral absorption limitations for more reliable dosing.

SubQ

Glutathione SubQ

200–600mg self-injected at home. Antioxidant, detoxification, and skin-brightening support as a sustained home protocol.

Oral

NAC (N-Acetyl Cysteine)

Glutathione precursor — 600–1800mg oral daily. Enhances endogenous glutathione synthesis. Standard oral adjunct for long-term antioxidant support.

Primary reason for interest in glutathione

B12, MIC & Lipotropic Injections

Methylcobalamin (B12) and MIC (Methionine, Inositol, Choline) injections support energy metabolism, fat metabolism, liver health, and neurological function. Often combined for synergistic effect.

SubQ / IM

Methylcobalamin B12

1000–5000mcg injection weekly. Superior to cyanocobalamin — active form directly usable by cells. Essential for energy, nerve function, and methylation support.

SubQ / IM

MIC Injection

Methionine + Inositol + Choline. Lipotropic injection supporting fat metabolism, liver detoxification, and cholesterol processing. Often used with weight loss programs.

SubQ / IM

Lipo-B / Lipo-C (MIC + B12 combo)

Combined MIC + B12 + additional B vitamins (B1, B2, B3, B6) for comprehensive lipotropic and energy support. Most complete lipotropic formulation.

B-Complex IM Injection

Full spectrum B vitamins (B1, B2, B3, B5, B6) in a single IM injection. Supports energy production, neurotransmitter synthesis, and adrenal health.

Known B12 deficiency or pernicious anemia?

Currently on Metformin? (Metformin depletes B12 — supplementation recommended)

Metabolic & Longevity Medications

Metformin and low-dose rapamycin are among the most studied longevity medications. Metformin activates AMPK, reducing cancer risk and extending healthspan. Low-dose rapamycin inhibits mTOR, one of the primary aging pathways.

Oral

Metformin (Longevity Protocol)

500–1500mg/day. Activates AMPK, reduces IGF-1, anti-cancer properties (TAME trial). Also improves insulin sensitivity and supports weight management alongside GLP-1 therapy.

Oral

Low-Dose Rapamycin

1–6mg once weekly. mTOR inhibition — the most validated anti-aging mechanism in mammals. Reduces senescent cell burden, improves immune function in aging.

Oral (Nightly)

Low Dose Naltrexone (LDN)

1.5–4.5mg nightly. Immune modulation, anti-inflammatory, autoimmune support. Increases endogenous endorphins. Used in fibromyalgia, autoimmune, Long COVID, and cancer protocols.

Oral

Berberine

500mg 2–3x/day. "Nature's Metformin" — activates AMPK, improves insulin sensitivity, lowers glucose and LDL. Excellent adjunct for metabolic optimization.

Are you currently taking Metformin?

Step 6 of 6

Informed Consent & Signature

Please read carefully. Your electronic signature is legally binding under Florida Statute §668.50.

Consent for Longevity & Wellness Therapies

Nature of Treatment

I am consenting to receive longevity and wellness therapies prescribed by a licensed Florida physician through Lavena Health. These may include NAD+ therapy, glutathione, B12 and MIC/lipotropic injections, and prescription longevity medications (Metformin, low-dose rapamycin, LDN, Berberine) as individually determined by my provider.

Off-Label & Compounded Medications

I understand that many longevity therapies are used off-label and some are compounded. Metformin and LDN require compounding for specific longevity doses. Low-dose rapamycin is off-label for aging. Compounded formulations are prepared by licensed pharmacies and have not undergone FDA pre-market review for these specific indications. I accept this as part of my informed decision.

Potential Benefits

NAD+: Improved cellular energy, cognitive function, DNA repair, and anti-aging
Glutathione: Antioxidant protection, detoxification, immune support, skin health
B12 / MIC: Energy, fat metabolism, liver health, neurological support
Metformin: AMPK activation, insulin sensitization, anti-cancer, longevity extension
Low-dose rapamycin: mTOR inhibition, reduced cellular senescence, immune rejuvenation
LDN: Immune modulation, anti-inflammatory, pain reduction, mood support

Risks & Side Effects

Glutathione: Rare allergic reaction; skin lightening with frequent high-dose use
Metformin: GI side effects at initiation; B12 depletion with long-term use; avoid in severe renal impairment
Rapamycin: Mouth sores, lipid changes; avoid in active infection
LDN: Vivid dreams initially; cannot combine with full-dose opioid medications
Injection site reactions possible with any SubQ or IM therapy

Monitoring & Lab Requirements

I agree to complete recommended baseline laboratory testing and follow-up monitoring at intervals determined by my provider. I will report any adverse reactions promptly.

Direct-Pay & Truthfulness

I certify all information is truthful and complete. Lavena Health is a cash-pay clinic — no insurance is billed. I may withdraw consent at any time.

Identity Verification

Why we ask: Florida law requires identity verification before prescribing. Your attestation satisfies this requirement for your initial intake.

I attest that I am the person named in this intake form and that all personal information provided is accurate and truthful.

I understand that a valid government-issued photo ID may be requested before my prescription is issued and I agree to provide one upon request.

I confirm I am a resident of the state selected and am physically located within that state at the time of this consultation request.

Date of Birth (re-enter to confirm identity)

Acknowledgments & Signature

I have read and understood the risks and benefits of all longevity and wellness therapies described above.

I understand that NAD+ injectable formulations, compounded glutathione, metformin prescribed for longevity indications, and other therapies listed in this intake are not FDA-approved for these specific uses. I accept this as part of my informed decision to pursue longevity and wellness medicine at Lavena Health.

I agree to complete baseline and follow-up laboratory testing as directed and will report any adverse effects promptly.

I confirm I am 18 or older, am the patient named in this form, and voluntarily consent to longevity and wellness therapies through Lavena Health. All information is truthful and complete.

Full Legal Name *

Or type your full legal name as your electronic signature

Today's Date *

Electronic Signature Notice: By typing your full legal name above and clicking Submit, you provide a legally binding electronic signature under Florida Statute §668.50 and the federal E-SIGN Act.

ID Verification — Optional but recommended

Upload a photo of your government-issued ID to verify your identity. This helps your physician review your file faster.

📷 Tap to photograph ID or upload a file JPEG, PNG or PDF · Max 6MB · Encrypted & HIPAA secure ID preview