Follow-Up Interview - ALL REVIEW INITIAL INTERVIEWProvider's Name: Date MM slash DD slash YYYY Confirm Practice information: How do practice members refer to the provider Primary contact email for our staff Primary contact phone number for our staff Practice Information notes:Confirm Coaching Option: Revitalize Health Coaching Coaching provided by them Confirm these coaching details: Process for scheduling office visits Process for receiving lab requisitions Discussion about Food Sensitivity Tests timing Option to recommend Keto Confirm these coaching details: Names of practice's coaches Phone number for practice member program-related questions Email for practice member program-related questions Method for practice members to schedule their coaching calls Additional Coaching NotesReview Dietary Transition Options: Revitalize Health transitions Keto transitions AIP transitions Non-Protocol Version Custom Dietary Transitions Review the submitted custom dietary transitions Confirm dietary transitions timing Confirm receipt of specific days and eliminations Review Post-Detox food reintroductions: Using Revitalize Health New reintroductions submitted Additional transitions notes:After reviewing the dietary transitions and confirming timing, please make any other necessary notes for preparing the scripts and filming.Review Supplement Protocol Options HereConfirm Supplement Protocol Option: Xymogen Ortho Molecular Fullscript Ortho + Fullscript (Mixed) Plant-Based Ortho Molecular Non-Protocol Custom Supplement Protocol Do you use a detox "shake" for your detox, or is it some other form of supplement? Yes No Details about the detox shake or other detox supplement:Confirm Detox length: 14 days (no change needed) Custom length Timing Option chosen: 7 Day Detox 21 Day Detox 28 Day Detox Other Review protocol provided to confirm "fit" into our curriculum. If other length is listed, please list length in "Additional Supplement notes" section.Additional Supplement NotesAfter reviewing the protocol, confirm program timing and make any necessary notes for preparing the scripts and filming.Confirm filming dates for Pro-level Confirmed Undecided Not Pro-level Review of Implementation GuideReviewed: Who to contact and How Program Structure and Layout Review of cholesterol, flu vaccine, and antibiotics content Documentary suggestion emails Office Visits & Labs in a Virtual Program Extra in-office Classes Demo Account to view programs Printing of program documents for a binder Coaching Guidelines Supplement Ordering Guide Using Program Dashboard Determining Start Date for practice members Keto information Review that they received the portal user guide and know how to use it Confirm portal user guide receipt Additional Notes for Development Staff
