MAYA – Patient Intake – KIDNEYRELIEF.LIFE

Step 1 of 9

Welcome to KidneyRelief.Life

You are in exactly the right place. Please take a few minutes to read about Dr. Priya and what this program offers before we begin your health history.

"I founded KidneyRelief.Life because I was tired of watching patients simply decline — being told 'there is nothing more we can do' when I knew there was more. A lot more."

— Dr. Priya Visweswaran Balakrishnan, MD

The GIG CKD Energy Restoration Program is a 6-week supervised clinical trial combining pharmaceutical-grade supplements, daily care team support, lab monitoring, live educational classes, and guided mind-body healing. Everything supervised directly by Dr. Priya.

Program fee: $1,000 (single) or $1,200 (monthly installments). One fully engaged participant may receive a complete tuition refund.

What this program is NOT:

This is not a cure for kidney disease. It does not replace your nephrologist. It does not guarantee eGFR improvement. It is not appropriate if you are medically unstable on dialysis. Dr. Priya will personally review every intake before enrollment is confirmed.

I have read the above and I am ready to begin my health intake

About You

Let's start with some basics so we can set up your file with Dr. Priya's team.

Legal First Name *

Legal Last Name *

Preferred Name / Nickname

Date of Birth *

Primary Phone *

Email Address *

City, State *

ZIP Code

Time Zone *

Best Time for Daily Call

Emergency Contact

Emergency Contact Name

Relationship

Emergency Contact Phone

How did you hear about KidneyRelief.Life?

Your Kidney Journey

Tell us about your kidney disease — how you got here, what you've been told, and where you are today.

When first diagnosed?

CKD Stage (if known)

Most Recent eGFR

Most Recent Creatinine

What is causing your kidney disease? (select all that apply)

eGFR trajectory

Dialysis Status — Important

Are you currently on dialysis? *

⚠️ ESRD Protocol Activated

Because you are on dialysis, Dr. Priya will personally review your intake before enrollment is confirmed. You will receive a call from Dr. Priya within 24 hours. A modified supplement introduction protocol (One at a Time) will apply to your program.

Kidney biopsy performed?

Do you have one kidney or two?

Your Lab Results

Share what lab values you have. Don't worry if you don't have all of them — just fill in what you know.

You can find these values on your lab reports, MyChart, or by calling your doctor's office. Even approximate values are helpful.

eGFR

Creatinine

BUN

UACR (urine protein)

Potassium

Bicarbonate / CO2

Hemoglobin

Vitamin D (25-OH)

HbA1c (if diabetic)

PTH

hsCRP (if known)

Phosphorus

Date of most recent kidney labs

Any other labs you'd like to share

Your Medications & Supplements

Please list every prescription medication, over-the-counter drug, vitamin, supplement, and herbal remedy you take. This is critically important for your safety.

⚠️ Safety Alert — NSAIDs

Ibuprofen (Advil, Motrin), naproxen (Aleve), and similar anti-inflammatory medications can reduce blood flow to the kidneys and accelerate kidney disease. Please list them honestly — Dr. Priya will review and advise. Do not stop any medication without your doctor's guidance.

List all prescription medications (name, dose, frequency)

List all OTC medications (Tylenol, antacids, sleep aids, etc.)

List all vitamins, supplements, and herbal remedies

Do you take any NSAIDs (ibuprofen, naproxen, celecoxib, etc.)?

Known drug allergies or sensitivities

Your Current Care Team

We'd like to know about the doctors currently caring for your kidneys so we can coordinate your care safely.

Primary Care Physician

Nephrologist

Cardiologist

Endocrinologist

Other specialists you see

May Dr. Priya's team communicate with your other doctors if medically necessary?

Your Goals & Your Story

This section matters most to Dr. Priya. She reads every word personally. Please answer in your own voice — there are no right or wrong answers.

"The numbers tell me about your kidneys. Your words tell me about you. Both matter equally."
— Dr. Priya

In your own words — what is going on with your health, and how has it affected your life? *

What symptom or problem bothers you the most right now? *

What would feeling better mean to you — what would you be able to do that you can't do now?

Is there someone in your life you are healing for?

What is your biggest concern about this program?

Anything else you want Dr. Priya to know about you?

Informed Consent

Please read each item carefully and check the box to confirm your understanding. This is your informed consent to participate in the KidneyRelief.Life GIG Program.

Your Full Legal Name (electronic signature) *

Today's Date *

✓

You Did It, [Name]

Your intake has been received. Dr. Priya will personally review everything within 48 hours and you will hear from her team very soon.

You have taken a real step today — not just for your kidneys, but for your whole life.

What happens next:
1. Dr. Priya reviews your intake (within 48 hours)
2. Welcome Packet sent to your email (within 24 hours)
3. Day 0 lab order sent to you
4. Your supplements shipped within 3–5 business days
5. Daily calls begin on Day 1 at your preferred time

Questions? Call us: (832) 439-6212
Email: care@kidneyrelief.life

KidneyRelief.Life