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
Step 2 of 6
Symptom Assessment
Rate each symptom over the past 4 weeks. 0 = None | 1–2 = Mild | 3–4 = Moderate | 5 = Severe
Weight gain, insulin resistance, blood sugar issues, high cholesterol
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.
IV Infusion
NAD+ IV Infusion
500–1000mg over 2–4 hours. Fastest and most complete cellular delivery. Ideal for acute energy restoration, addiction recovery, and neurological conditions.
SubQ Injection
NAD+ SubQ Injection
100–500mg self-administered at home. More convenient than IV, avoids GI side effects of oral. Ideal for maintenance protocols after initial IV loading.
Oral
NAD+ Precursors (NMN / NR)
Nicotinamide Mononucleotide (NMN) or Nicotinamide Riboside (NR) — oral NAD+ precursors for daily maintenance. Best combined with resveratrol or pterostilbene.
Intranasal
NAD+ Intranasal
Direct CNS delivery via nasal mucosa. Particularly effective for cognitive enhancement, mood improvement, and neurological applications.
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. IV and SubQ delivery bypass oral absorption limitations.
IV Push
Glutathione IV Push
1000–3000mg IV push over 10–15 minutes. Most potent delivery. Immediate antioxidant, detoxification, and skin brightening effects. Often combined with vitamin C drip.
SubQ
Glutathione SubQ
200–600mg self-injected at home. Excellent for maintenance and home protocols between IV sessions.
Intranasal
Glutathione Intranasal
Direct CNS antioxidant delivery. Used in Parkinson's protocols and neuroinflammation management. 200–400mg per administration.
Oral
NAC (N-Acetyl Cysteine)
Glutathione precursor — 600–1800mg oral daily. Enhances endogenous glutathione synthesis. Standard adjunct to IV protocols.
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.
IM
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.
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.
Step 4 of 6
Medical History
Accurate medical history ensures safe longevity therapy prescribing.
Active Medical Conditions
Select all that apply.
Active cancer or history of cancerSome longevity therapies require modification with active malignancy
Kidney diseaseImportant for NAD+ and Metformin dosing
Liver diseaseImportant for glutathione and lipotropic therapies
Autoimmune conditionLDN requires careful consideration in autoimmune patients on immunosuppressives
Psychiatric or neurological conditionDepression, anxiety, ADHD, Parkinson's, MS
None of the above
Additional History
Step 5 of 6
Medications, Supplements & Labs
List all current medications and any recent lab values. This is critical for safe longevity protocol design.
Current Medications
Lifestyle
Recent Lab Values
Enter any recent bloodwork you have. If you don't have values, leave blank — we will provide a comprehensive longevity lab panel order after reviewing your intake.
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
1
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.
2
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.
3
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
LDN: Immune modulation, anti-inflammatory, pain reduction, mood support
4
Risks & Side Effects
NAD+ IV: Nausea, flushing, chest tightness during infusion — managed by slowing infusion rate
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
5
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.
6
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.
Acknowledgments & Signature
I have read and understood the risks and benefits of all longevity and wellness therapies described above.
I understand that some therapies are off-label or compounded and accept this as part of my decision to pursue longevity medicine.
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.
Type your full name as your electronic signature
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.
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Form Submitted
Thank you for completing your Longevity & Wellness Intake. Your information has been securely received by Lavena Health.
A physician will personally review your intake and contact you within 1-2 business days to discuss your personalized longevity protocol.