Custom Branded Program Specifications (Pro)

CUSTOM BRANDED PROGRAM SPECIFICATIONS

Please fill out the form below. The information you submit will be used to customize your virtual programs, so please double-check for accuracy before submitting. If you have any questions, please reach out to our team at 936-321-7800 or program@revitalizehealth.com.

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Tracking Email
Practice Name*
Provider's Name*
First Last
Additional Provider's Name
First Last
(if applicable)
How did you hear about us?*
Who is your coach?*
Who referred you to us?*
By what name do your practice members refer to your primary provider(s)?*
i.e., "Dr. Smith, Dr. Bob, Bob, Dr. S."
Main Provider's (Owner) Email*
Practice Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Best phone number for our staff to communicate with the Practice*
Primary Practice Contact for our staff*
Best email for our staff to communicate with the Practice*
Who will be entering patients into the program?*
Who should we contact when your Virtual Program is ready?*
Practice Website*
Coaching Options
Are you going to use Revitalize Health coaches for your programs?*
- Yes
- No
Using Revitalize Health coaches for your programs will require an additional per-member fee paid upon practice member registration.
Please fill out the following questions so our coaches can better understand how to coach your practice members. If you don't know the answer, just fill in the questions with "unknown" and we can follow up at a later date to discuss. Thanks!
Primary provider’s education and specialty:*
Length of time in practice:*
Time zone in which practice is located:*
Which lengths of virtual curriculum will you be offering?*
- Select All
- 30 Days
- 60 Days
- 3 Months
- 4 Months
- 6 Months
Types of practice members you typically work with:*

Examples include SHH, Diabetes, Thyroid, Autoimmune, Cognitive decline, etc.
What are the names and job title of all of your staff members:*
What is the process for scheduling in office visits?*

Examples include scheduling by phone, online portal, etc
If scheduling by phone or in the office, who do the practice members speak with to schedule?*
How often do in-office visits take place with a provider?*

Examples include monthly, every 6 weeks, every 3 months. etc.
What types of labs are utilized for practice members?*

Examples include blood, stool, saliva, urine, etc
How do practice members receive their lab requisitions?*
Do you offer any specialty testing?*

Examples include Food Sensitivity Testing, Brain Map (QEEG), Genetics, etc.
What additional testing or treatments do you offer?*

Examples include acupuncture, bHRT, chiropractic, IV nutrition, PEMF, Neurofeedback, etc.
If a practice member has a question for the doctor or about an additional supplement, how would you like us to respond?*
- Let me check with Dr. ____ and get back to you.
- Let me check with Dr. ____ and someone will reach out regarding that.
Which supplement brands do you use in the office?*

Examples include Xymogen, Designs for Health, Orthomolecular, Metagenics, etc.
If you have a patient who is having a hard time losing weight or at a plateau, would you be ok with us recommending Ketogenic principles?*
Name(s), Email Address(es), and Phone(s) of Your Coaches:
In your program emails, what phone number do you want us to tell practice members to call for program questions?*
What email address do you want practice members to utilize for program-related questions?*
What method would you like your patients to schedule their coaching calls?*
- The patient calls your office to schedule their coaching call. We give them several reminders to schedule this call and notify you prior to when it is supposed to take place.
- Using an online scheduling system that will allow coaches to set availability and the patient will simply click the link in the email to schedule their call. (This requires you to set up a scheduling software, if you do not already have one, such as Calendly, ScheduleOnce, MPN, etc.)
- I do not want to have patients schedule calls. We will schedule these in advance with each patient.
Do you want to be notified whenever it is time for the coaching call to take place?*
- Yes
- No
Dietary Transition Options
REMINDER!
Unless you want us to create a proposal for creating custom dietary transitions, you will be required to follow our dietary transition structure of thirty (30) days of dietary transitions, followed by a detox period.

Review the Revitalize Health dietary transitions here: Dietary Transitions for Custom Branded Programs
Confirm the dietary transitions you are using:*
- Revitalize Health transitions
- I want to customize the dietary transitions
NOTE: Once our team has reviewed the customizations you are requesting, we will reach out with a proposal outlining what is required to complete these changes.
How many days do your dietary transitions last?*

Examples include 14 days, 21 days, 28 days, etc.
Upload your dietary transitions here:*
Max. file size: 50 MB.
Please provide specific days, eliminations, and specifics concerning why you are asking them to eliminate these foods.
Post-detox, we have the practice members begin food reintroduction according to the following principles.

Review the Revitalize Health food reintroduction process: Food Reintroduction Guidelines for All Programs
Will you use these food reintroduction guidelines for your program?*
- Yes
- No
Upload your food reintroduction protocol here:*
Max. file size: 50 MB.
Please provide the specific rules and steps you ask practice members to take for reintroducing foods, including which foods to test and the order in which to do so, if applicable. Please note which of the eliminated foods should not be reintroduced, or reintroduced sparingly, along with notes about why you are asking them to follow these steps.
Supplement Options
REMINDER!
As a Professional level doctor, you may use one of our supplement protocols or have us integrate your supplement protocol into the program. Alternatively, you can use the "non-protocol" version of our curriculum that removes the mention of any specific supplement protocol or company. General supplement information discussing the benefits of probiotics, fish oil, and vitamin D, for example, is still referenced in the program.

Review the supplement protocols here: Supplement Protocols for Custom Branded Programs
Confirm which protocol you are using:*
- Xymogen
- Ortho Molecular
- Fullscript
- Ortho + Fullscript
- Plant-Based Ortho Molecular
- Non-Protocol Version
- Custom Supplements
Note: If you are using the Xymogen protocol but private labeling them with your brand, choose Xymogen.
What is the length of your detox?*
- 7 Days
- 14 Days
- 21 Days
- 28 Days
Upload Your Supplement Protocols Here:*
Drop files here or

Max. file size: 50 MB.
These are core supplements only, not customized supps given after consults or testing. Please provide the names of the supplements, which program days they are taken, and the instructions for taking each supplement, including quantity, time of day, and any additional instructions required to take.
Are you going to have Revitalize Health order and fulfill your supplements?*
- Yes
- No
This only applies to first 60-days of core supplement protocols. If you wish to provide additional supplements to practice members based on consults, labs, or testing, these must be provided by your office. Providing the first 60 days of supplements for your practice includes an added, per-patient fee.
Filming Options
Preferred Video Production Dates*
Please list out your preferred dates for video production. Filming occurs on Monday/Tuesday or Thursday/Friday. Weekends are not available. Two consecutive days of filming are required. Please give 3-4 options, in preferential order, as this will help our team coordinate the best available time with you.
Who is going to be featured in the videos?*
Can be multiple staff members
Logo & Staff Picture
Practice Logo
Drop files here or

Max. file size: 50 MB.
Please include a high-resolution graphic of your practice's logo. If you do not have a logo, please reach out to our team about design services. Minimum recommended height: 900px.
Picture of Doctor & Staff
Drop files here or

Max. file size: 50 MB.
Please include a picture of your practice's doctor and/or coaching staff. Please designate the person in the picture in the file name.
Do you have any additional questions or requests?

Coaching Options

Dietary Transition Options

Supplement Options

Filming Options

Logo & Staff Picture