Introduction

THIS INFORMED CONSENT FOR INTRANASAL NAD+ (THE "CONSENT") SETS FORTH THE TERMS AND POLICIES FOR THE CLINICAL SERVICES PROVIDED BY SUPERPOWER MEDICAL GROUP OF CA PC, A CALIFORNIA PROFESSIONAL MEDICAL CORPORATION, AND OTHER THIRD-PARTY MEDICAL GROUPS (THE "MEDICAL GROUPS") THROUGH THE ONLINE TECHNOLOGY PLATFORM ("PLATFORM" OR "SUPERPOWER PLATFORM"), WHICH IS OWNED AND OPERATED BY SUPERPOWER HEALTH, INC. ("SUPERPOWER"). ‍

This informed consent is for the use of intranasal nicotinamide adenine dinucleotide (NAD+), a coenzyme involved in numerous cellular processes, for the potential treatment of age-related conditions and overall wellness optimization. The purpose of this consent is to provide you with information about the risks, benefits, and safety considerations associated with intranasal NAD+ treatment in order for you to make an informed decision as to whether or not to proceed with treatment, as well as to obtain your agreement to adhere to the treatment protocol as prescribed by your Medical Group healthcare provider (“Healthcare Provider”). Please read this form carefully and ask any questions you have before signing.‍

General Information

Intranasal NAD+ has emerged as a potential therapeutic strategy to replenish cellular NAD+ levels and combat age-related diseases. Intranasal delivery allows for rapid absorption of NAD+ into the systemic circulation and may offer advantages over oral or parenteral routes, such as enhanced bioavailability and reduced first-pass metabolism. Intranasal NAD+ is not FDA approved and is regulated as a dietary supplement that requires a prescription from a licensed clinician. ‍

Risks and Side Effects‍

While the safety profile of intranasal NAD+ in humans has not been extensively studied, and data on potential side effects and long-term safety are limited, some potential side effects may include:

Nasal irritation or discomfort
Nasal congestion or rhinorrhea
Headache
Dizziness
Changes in sense of smell or taste
Systemic effects (e.g., flushing, nausea, diarrhea) due to absorption into the circulation‍

Contraindications

Intranasal NAD+ may be contraindicated in the following situations:

Known allergy to NAD+ or any components of the intranasal formulation
Severe nasal pathologies or anatomical deformities that may impair absorption
Active nasal infections or inflammation
Recent nasal surgery or trauma
Pregnancy and lactation (safety unknown)
Severe hepatic or renal impairment (metabolism and excretion may be altered)
Chronic nasal conditions (e.g., allergic rhinitis, sinusitis) that may affect absorption
Cardiovascular disease (theoretical risk of systemic effects)
Bleeding disorders (theoretical risk of nasal mucosal bleeding)
Studies have shown that there is potential that higher levels of nicotinamide riboside could increase the risk of developing triple-negative breast cancer and may cause the cancer to metastasize to the brain. Therefore, you should NOT use NAD+ in any treatment if you have cancer or a history of cancer.

If any of these contraindications apply to you, inform your Healthcare Provider before starting treatment.‍

Treatment Protocol

Your Healthcare Provider will determine the appropriate dosage of intranasal NAD+ based on your individual needs and medical history. This can be given as 1-2 sprays per nostril of a standardized solution. Treatment should begin at the lower end of the range and titrate up slowly based on tolerability and response.Once a stable well-tolerated dose is achieved, it can be continued long-term with periodic monitoring. The ideal duration of treatment is undefined. Clinical response, patient preference, and emerging research should guide maintenance therapy. Intermittent dosing cycles may be considered.‍

Use of Telehealth

You understand that all Clinical Services will be provided via telehealth. Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to, one or more of the following:‍

Electronic transmission of client medical records, photo images, personal health information or other data between a patient and a provider;
Interactions between a patient and provider via audio, video and/or data communications (such as messaging or email communications);
Use of output data from medical devices, sound and video files.
Alternative methods of care may be available to you, such as in-person services, and you may choose an alternative at any time.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of customer identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.‍

Expected Benefits of Telehealth:

Improved access to care by enabling a customer to remain at a remote site while consulting with practitioners at distant/other sites.
More efficient client evaluation and management.‍
Obtaining expertise of a distant specialist.‍

Possible Risks of Telehealth:

There are potential risks associated with the use of telehealth. These risks include, but may not be limited to:‍

There is the potential that conditions that could be diagnosed with an in-person visit may go undetected in a remote encounter especially because a full physical exam cannot be performed
In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by the Healthcare Provider;
Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment;
In very rare instances, security protocols could fail, causing a breach of privacy of personal health information;
In rare cases, a lack of access to complete health records may result in interactions or allergic reactions or other judgment errors.

Due to state licensure requirements for healthcare providers, you have to physically be in the state that your Healthcare Provider is licensed in during your telehealth visit. By agreeing to this Consent, you are confirming that you will only opt in to care when you are in your state of residence or in one of our locations. Furthermore, you are confirming that your state of residence is one in which the Medical Groups are licensed to treat.

PLEASE NOTE: THE MEDICAL GROUPS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, ARE CONSIDERING HARMING YOURSELF OR OTHERS, OR ARE OTHERWISE IN IMMINENT DANGER, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM.

You should seek emergency help or follow-up care when recommended by any healthcare provider or when otherwise needed. You should never discontinue medications or stop a course of treatment without first contacting your primary care provider or other medical professionals for advice. You should not delay treatment or advice from your primary care provider or other medical professionals based on information provided by the Healthcare Provider(s) via the Superpower Platform.

All laws and protections for in-person medical care also apply to telehealth care. This includes confidentiality of information, access to medical records, and sharing of information that could identify you personally. You may decide that you do not want to use the Clinical Services at any time, seek treatment elsewhere and/or with in-person offerings.

Informed Consent & Adherence to Treatment Plan

Please sign below to acknowledge your understanding and agreement of the following terms in order to proceed with treatment with intranasal NAD+ therapy with a Medical Group Healthcare Provider via the Superpower Platform:

BY SIGNING THIS INFORMED CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND THE INFORMATION PROVIDED ABOUT INTRANASAL NAD+ TREATMENT, INCLUDING THE RISKS, BENEFITS, AND SAFETY CONSIDERATIONS. YOU AGREE TO ADHERE TO THE TREATMENT PROTOCOL AS PRESCRIBED BY YOUR HEALTHCARE PROVIDER AND TO REPORT ANY SEVERE SIDE EFFECTS OR CONCERNS TO YOUR HEALTHCARE PROVIDER PROMPTLY.

Use the intranasal NAD+ exactly as directed by your Healthcare Provider. Do not use more of it, do not use it more often, and do not use it for a longer time than your Healthcare Provider ordered.

No Guarantees or FDA Approval:

You acknowledge that there are no guarantees or assurances made with respect to the results of using intranasal NAD+, and there are no guarantees that there will not be side effects and complications. Additionally, you understand that NAD+ is not an FDA approved medication and the FDA has not approved it to diagnose, treat, cure or prevent any medical condition.

Complete Medical History:

You understand that use of intranasal NAD+ may be inappropriate and unsafe if you have certain health conditions, allergies, or take certain medications or supplements, whether prescribed or over-the-counter. For this and other reasons, you understand that it is vital that you truthfully and accurately disclose all health information requested by your prescribing Healthcare Provider including allergies, medications you are taking (both prescription and over the counter), medical/surgical/social/family history, and pertinent lab results, and keep your Medical Group prescribing Healthcare Provider updated as to any changes in your health conditions and history during use of intranasal NAD+ and you agree there shall be no liability on the part of the Medical Groups, the Healthcare Providers or Superpower if you fail to do so.

BY CLICKING "I AGREE" OR OTHERWISE INDICATING YOUR ACCEPTANCE, YOU ARE PROVIDING YOUR INFORMED CONSENT TO RECEIVE INTRANASAL NAD+ TREATMENT THROUGH THIS SERVICE. YOU CERTIFY THAT YOU ARE NOT CONSENTING ON BEHALF OF A MINOR CHILD, AS THIS SERVICE DOES NOT PROVIDE TREATMENT TO INDIVIDUALS UNDER THE AGE OF 18.

MEMBER NAME:___________________________

SIGNATURE:_____________________________

DATE:__________________________________

Informed Consent for Intranasal NAD+ Treatment