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
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.