Patient intake form

Welcome to iollo — we're excited to have you join us on this journey towards better health!

Would you like to learn more about iollo?

Learn More About iollo

A

Yes - I'd like to learn more about iollo 📚

B

No - I'm ready to get my iollo testing kit now 🛒

Our blood test provides unique and deeper insights into your overall health by analyzing 600+ biomarkers. Using this information, we create personalized recommendations just for you, to help you feel your best. 🌟 💰 Special discounted pricing available! The retail value of each iollo kit is $499, but you’re getting it at an exclusive rate.

To get started and avail of your iollo kit, simply complete this form and payments page. You will automatically be redirected to a payments page after completing this form.

Thanks again for choosing iollo. We can't wait to help you unlock a healthier, happier you!

What's your name?

What's your date of birth?

Have you been diagnosed with ALS?

A

Yes

B

No

The benefit of participating in this study is the personalized report you will receive about your metabolism from Iollo. This report will include basic suggestions for possible improvements in your metabolic health. This information is not intended to change the course of ALS symptoms. However, your participation will help researchers identify the metabolic signature of ALS and will contribute to the search for a cure.

Do you have any additional medical diagnoses?

Current Prescription Medications

Vitamins and Supplements Used

Special Diet or Dietary Restrictions

How often would you want to take a iollo test?

Would you like to pay with an HSA/FSA card? 5% processing fee applies to HSA/FSA payments

I have read iollo's Consent for Sharing Health Data and do give my consent to share my deidentified health data with Dr. Naviaux and Neurodegenerative Disease Research (NDR). By giving this consent, I authorize iollo to share my health data, health results, and self-reported information after removal of my name with Dr. Naviaux and Neurodegenerative Disease Research (NDR). I understand that purchasing an iollo test kit and sharing results with Dr. Naviaux and Neurodegenerative Disease Research (NDR) does not establish a doctor-patient relationship if one does not already exist. If I am not currently a Dr. Naviaux and Neurodegenerative Disease Research (NDR) patient, this consent for data sharing alone does not create a medical care relationship.

A

I agree