Welcome to our new Patient Enrollment form.

Please enter your patient's details below. Patients should ideally be registered a minimum of 1-2 days before they are to begin the purification program. However, we automatically do a 'catchup' for any patients enrolled after their start date.

If you have any questions, please don't hesitate to contact us using the link to the left.

Practitioner's Email Address *

This is used to identify your account.
Patient's Email Address *

Please enter the patient's email address. Accuracy is very important.
Patient Name * First Last
Please enter the patients' first and last name. Using proper case (John Doe) comes across much more professional than all caps (JOHN DOE) or all lowercase (john doe).
Purification Start Date / MM / DD YYYY
Please enter the the date the patient is beginning the purification program.
Unknown Start Date Unknown Start Date
Choose this option if you do not know the patient's start date. A welcome email will be sent to the patient asking them to verify their start date.
Patient Zip Code

This is used to better understand where patients enrolled in our service are located. This field is optional.
Comments / Special Instructions to your Patient

Anything you place in this field will be included in the Patient's welcome email. You can include an encouraging statement such as "Have fun and BE DETERMINED, it will pay off in the long run!" or "Remember to avoid lentils and rice to achieve your goals."
Comments to Purification Support

These comments are for Purification Support staff and will NOT be visible to the patient.