CONTACT INFORMATION

First Name *

Last Name *

Phone *

Email *

Before we can ship an at-home wellness kit, we ask a few quick safety questions. This takes about 30 seconds. There are some health situations where the at-home format is not the most appropriate starting point — and if any of these come up, we'll let you know and help you find the right path instead.

QUESTIONNAIRE

1) Are you currently undergoing active cancer treatment, or have you been diagnosed with cancer that is not currently in remission? *

YES

This includes chemotherapy, radiation, immunotherapy, or any active oncology protocols.

2) Are you currently pregnant, planning pregnancy in the next 90 days, or breastfeeding? *

YES

This includes all trimesters and the breastfeeding period.

3) Are you currently taking immunosuppressive medications? *

YES

This includes transplant rejection medications, any drugs for autoimmune conditions (such as Humira, Enbrel, Remicade, Rituxan), or high-dose corticosteroids taken regularly.

4) Are you currently experiencing an active infection, fever, or acute illness — or have you been hospitalized in the past 30 days? *

YES

This is temporary. If you answer Yes, we may be able to revisit your application once you've recovered and are more stable.

By checking this box, I have answered all questions truthfully and acknowledge that this is a private-membership educational wellness program — not medical advice, diagnosis, or treatment. I am 18 or older and consent to be contacted by PURE Advanced Biologics.

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