[[[["field30","contains",""]],[["show_fields","field33"]],"and"],[[["field35","contains"]],[["show_fields","field36"]],"or"],[[["field1","contains","Y"]],[["show_fields","field6,field3"]],"and"],[[["field41","contains","Y"]],[["show_fields","field42,field43"]],"and"],[[["field44","contains","Y"]],[["show_fields","field45,field48"]],"and"],[[["field50","contains","Y"]],[["show_fields","field51"]],"and"],[[["field52","contains","Y"]],[["show_fields","field53,field54"]],"and"],[[["field55","contains","Y"]],[["show_fields","field56,field57"]],"and"],[[["field58","contains","Y"]],[["show_fields","field59"]],"and"],[[["field60","contains","Y"]],[["show_fields","field62"]],"and"],[[["field63","contains","Y"]],[["show_fields","field64,field65"]],"and"]]
1 Step 1
2 Step 2
3 Step 3
4 Step 4
5 Step 5
6 Step 6
First Name:your first name
Last Name:your last name
Street Address - Line 1
home e88a
Street Address - Line 2
City
State
Zip
Phone
phone e0cd
Age
Weight
Height
Commentsmore details
0 /
Do you suffer from:
Explain (Optional)more details
0 /
Exercise type?Choose any that apply
Othermore details
0 /
Greatest issues:
Anything Else? (Really - We can handle it).more details
0 /
Greatest health desires / goals?
What Else?more details
0 /
Do you eat...
Do you drink coffee?
Your regular coffee size?
How many cups do you have in a day?
Do you drink tea?
Serving size (average)
How many cups do you have in a day?
Do you drink energy drinks?
How many do you have in a day?
Any other stimulants?more details
0 /
Are you sensitive to stimulants?
In what way?more details
0 /
Do you use prescription drugs?
What kind?
0 /
For what condition(s)?
0 /
OTC drugs? (aspirin, antihistamines, etc.)
What kind?
0 /
For what condition(s)?
0 /
Are you taking anti-depressants / SSRI's?
What brand / name / type?
Are you taking an MAO inhibitor?
What brand / name / type?your full name
Are you taking...
Are you taking any supplements or herbs?
What kind?more details
0 /
Why, and how often?more details
0 /
Taste sensitivity?

Please adjust each aspect of your Nootropic Blend to get the perfect mix and elements - Not too much or too little - Just right

When you order, you can make significant changes to your mix. Go Wild!

FocusAbility to Stay On-Task for Extended Periods
0
0
5
EuphoriaA Relaxed Feeling. Improved Lateral Thinking.
0
0
5
EnergyOverall Wakefulness.
0
0
5
ConfidenceImproves Decision-Making Capacity
0
0
5
CalmReduced Anxiety. Less Stress.
0
0
5
Restoramones (Additive)(Prohormone Booster - Enhances Nootropics)
0
0
5
*NZT-48 BETA TEST STIM STACK*(Existing Customers and Athletes Only, Please!)
0
0
5
Any additional information or insights to share?more details
0 /

And... you're done! Simply click the submit button and select your Custom Blended Nootropics. Please let us know how we did on the FEEDBACK FORM.

keyboard_arrow_leftPrevious
Nextkeyboard_arrow_right