Provider Registration

Diabetes RemissioN is the New End Goal

Register YOUR PRACTICE Today

1. HEALTH CARE PROVIDER INFORMATION

Health Care Provider Name (Last, First)

Phone Number

Fax Number

Practice Name

Street

Email Address

City

State

Zip Code

Office Staff Contact Name (First, Last)

2. Patient management expectations
I am willing to manage patients that I enroll in the L-Nutra Health for Diabetes ProgramI am willing to receive patients referred to me to manage their diabetes medications when participating in the L-Nutra Health for Diabetes ProgramI understand that I am responsible for the medical management of the patient's diabetes during the Program including laboratory testing, glucose monitoring and medication adjustment as needed
3. HEALTHCARE PROVIDER AUTHORIZATION
I agree to be responsible for the medical management of the patient’s diabetes including laboratory testing, glucose monitoring and medication adjustment as needed during the Program, L-Nutra Health for Diabetes.

My patient will not have any of the following exclusion criteria for the program: Generally unstable; end-stage renal diseases; unsuitable to go through a 5-day low calorie nutrition program; <18 years old; a BMI <20; chronic heart failure class III or above; cardiac arrhythmia; recent myocardial infarction (< 6 months); history of syncope with calorie restriction in the past; creatinine clearance < 30 ml/min; major psychiatric disorder (e.g., schizophrenia, bipolar disorder); currently pregnant or nursing, or planning to become pregnant during the program; food allergy for ingredients in the fasting nutrition program, including nuts, celeriac/celery, oats, and sesame.
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L-NUTRA HEALTH FOR DIABETES REMISSION IS NOW WITHIN REACH

L-Nutra Health for Diabetes is centered around a monthly 5-day regimen of scientifically formulated, plant based FMD Nutrition and a robust support system that keeps focus and motivation for the new end goal - remission of diabetes.

1. HEALTH CARE PROVIDER INFORMATION

2. Patient management expectations

3. HEALTHCARE PROVIDER AUTHORIZATION