Provider Registration

Diabetes RemissioN is the New End Goal

Register YOUR PRACTICE Today

OVERSEEING HEALTHCARE PROVIDER INFORMATION
Health Care Provider Name (First, Last)
Practice Name
Provider credentials to be listed on the site
Office Staff Contact Name (First, Last)
Office Staff Contact Email Address
*
General Office Phone Number
Office Fax Number (must be used for sharing patient information)
Dr.'s Email Address (will be used for our Rd's to reach out if necessary)
*
Doctor's Phone Number (will be used when RD needs to speak with doctor urgently)
City clinic is located in
State clinic is located in
If you have a current Prolon Stripe account, please list the email address used for that Stripe account
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 quarterly laboratory testing, quarterly doctor visits, glucose monitoring and medication adjustment as needed.
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 diseases; unsuitable to go through a 5-day low calorie nutrition program; BMI <20; CHF 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 to 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.

OVERSEEING HEALTHCARE PROVIDER INFORMATION

PATIENT MANAGEMENT EXPECTATIONS

HEALTHCARE PROVIDER AUTHORIZATION