Signup Form Virtual Health & Supplement Program

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Name* This field is required.
First Name
Last Name
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Business Name * This field is required.
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E-mail* This field is required.
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Cell Phone Number (for our purpose only)* This field is required.
Area Code
Phone Number
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What is your web address?* This field is required.
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Are you a US or Canadian Healthcare Practitioner?* This field is required.
Canadian
US
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Which one of the 6 online programs would you like?* This field is required.
Immune Support
Weight Loss
Detox & Cleanse
Stress Program
Anti-Inflammatory Program
Brain Program
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Immune Support Program

The Immune Support Program will be set up with the following supplements & food plan. These selections have proven to be the most successful and we strongly recommend them. Should you really want to customize these supplements due to specific needs, please let us know in the special request field at the end of this questionnaire. Scroll down for Canadians.

US Version

Immune Support Packets
https://shop.designsforhealth.com/immune-support-packet

ProbioMed 50
https://shop.designsforhealth.com/probiomed-50

Food Plan - 28-day Immune Support Daily Meal Guide
https://drive.google.com/file/d/1jtkodrAZ7UcmhKFqJ5HliBPVgSctsHtw/view?usp=sharing

Canadian Version

ProbioMed 50
https://shop.designsforhealth.ca/ProbioMed50-CN

Zinc Supreme
https://shop.designsforhealth.ca/Zinc-Supreme-CN

Emulsi-D3 Synergy
https://shop.designsforhealth.ca/Emulsi-D3-Synergy-2oz-liquid-CN

Immunitone Plus Capsules
https://shop.designsforhealth.ca/Immunitone-Plus-Capsules-CN

N-Acetyl-Cysteine
https://shop.designsforhealth.ca/N-Acetyl-Cysteine-CN

CBio-Fizz-Effervescent-Powder
https://shop.designsforhealth.ca/CBio-Fizz-Effervescent-Powder-CN

Food Plan - 28-day Immune Support Daily Meal Guide
https://drive.google.com/file/d/1jtkodrAZ7UcmhKFqJ5HliBPVgSctsHtw/view?usp=sharing
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Anti-Inflammatory Program

The Anti-Inflammatory Program will be set up with the following supplements & food plan. These selections have proven to be the most successful and we strongly recommend them. Should you really want to customize these supplements due to specific needs, please let us know in the special request field at the end of this questionnaire. Scroll down for Canadians.

US Version

SPM Supreme

https://shop.designsforhealth.com/spm-supreme

Inflammatone™

https://shop.designsforhealth.com/inflammatone

Omega Avail Hi-Po

https://shop.designsforhealth.com/omegavail-hi-po

Food Plan - 28-day Anti-Inflammatory Meal Guide

Canadian Version

Inflammatone™

https://shop.designsforhealth.ca/Inflammatone-vegicaps-CN

Curcum-Evail Softgels

https://shop.designsforhealth.ca/Curcum-Evail-CN

Omega Avail Hi-Po

https://shop.designsforhealth.ca/OmegAvail-Hi-Po-capsules-CN

Food Plan - 28-day Anti-Inflammatory Meal Guide
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Detox & Cleanse Program

The Detox & Cleanse Program will be set up with the following supplements & food plan. These selections have proven to be the most successful and we strongly recommend them. Should you really want to customize these supplements due to specific needs, please let us know in the special request field at the end of this questionnaire. Scroll down for Canadians.

US Version

VegeCleanse Plus 14-Days Detox Program
https://shop.designsforhealth.com/VegeCleanse-Plus-14-Day-Detox-Program

ProbioMed 50
https://shop.designsforhealth.com/probiomed-50

Food Plan - VegeCleanse-14-days Meal Plan
https://drive.google.com/file/d/1hFPI8v3u7r4UbDwdN221qEsJuHTJPBSO/view?usp=sharing

Canadian Version

PaleoCleanse Plus™ 14 Day Detoxification Program
https://shop.designsforhealth.ca/PaleoCleanse-Plus-14-Day-Detoxification-Program

ProbioMed 50
https://shop.designsforhealth.ca/ProbioMed50-CN

Food Plan - VegeCleanse-14-days Meal Plan
https://drive.google.com/file/d/1hFPI8v3u7r4UbDwdN221qEsJuHTJPBSO/view?usp=sharing
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Weight Loss Program

The Weight Loss Program will be set up with the following supplements & food plan. These selections have proven to be the most successful and we strongly recommend them. Should you really want to customize these supplements due to specific needs, please let us know in the special request field at the end of this questionnaire. Scroll down for Canadians.

US Version

Probiomed 50
https://shop.designsforhealth.com/probiomed-50

Weight Loss Support Packets
https://shop.designsforhealth.com/weight-loss-support-packets

Food Plan - Low Sugar Challenge 28 days
https://drive.google.com/file/d/1-HxhxRnqhLJ8ccKm0x8Pdy1RE-MFvxct/view?usp=sharing

Canadian Version

Berb-Evail
https://shop.designsforhealth. ca/Berb-Evail-CN

Endotrim
https://shop.designsforhealth. ca/Endotrim-CN

Carnitine-Synergy
https://shop.designsforhealth. ca/Carnitine-Synergy-CN

ProbioMed 50
https://shop.designsforhealth.ca/ProbioMed50-CN

Food Plan - Low Sugar Challenge 28 days
https://drive.google.com/ file/d/1- HxhxRnqhLJ8ccKm0x8Pdy1RE- MFvxct/view?usp=sharing
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Stress Program

The Stress Program will be set up with the following supplements & food plan. These selections have proven to be the most successful and we strongly recommend them. Should you really want to customize these supplements due to specific needs, please let us know in the special request field at the end of this questionnaire. Scroll down for Canadians.

US Version

Omega Avail

https://shop.designsforhealth.com/omegavail

Magnesium Buffered Chelate

https://shop.designsforhealth.com/magnesium-buffered-chelate

Catecholacalm

https://shop.designsforhealth.com/catecholacalm

B Supreme

https://shop.designsforhealth.com/b-supreme

Probiomed-50

https://shop.designsforhealth.com/probiomed-50

Food Plan - Adrenal Support Cleanse 28 Days

Canadian Version

Omega Avail

https://shop.designsforhealth.com/omegavail

Magnesium Glycinate Chelate

https://shop.designsforhealth.ca/Magnesium-Glycinate-Chelate-CN

Catecholacalm

https://shop.designsforhealth.com/catecholacalm

B Supreme

https://shop.designsforhealth.com/b-supreme

Probiomed-50

https://shop.designsforhealth.com/probiomed-50

Food Plan - Adrenal Support Cleanse 28 Days
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Brain Program

The Brain Program will be set up with the following supplements & food plan. These selections have proven to be the most successful and we strongly recommend them. Should you really want to customize these supplements due to specific needs, please let us know in the special request field at the end of this questionnaire. Scroll down for Canadians.

US Version

CogniAid
https://shop.designsforhealth.com/cogniaid

OmegAvail Hi-Po
https://shop.designsforhealth.com/omegavail-hi-po

Brain Vitale
https://shop.designsforhealth.com/brain-vitale

S-Acetyl Glutathione Synergy
https://shop.designsforhealth.com/s-acetyl-glutathione-synergy

Food Plan - 28 Day Mediterranean Food Plan

Canadian Version

Brain Vitale
https://shop.designsforhealth.ca/Brain-Vitale-CN

OmegAvail-Hi-Po
https://shop.designsforhealth.ca/OmegAvail-Hi-Po-capsules-CN

Resveratrol Synergy
https://shop.designsforhealth.ca/Resveratrol-Synergy-CN

N-Acetyl-Cysteine-CN
https://shop.designsforhealth.ca/N-Acetyl-Cysteine-CN

Food Plan - 28 Day Mediterranean Food Plan
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What would you like your program to be named? Example: Dr. Mary's Detox and Cleanse, Dr. Smith's Detox & Cleanse or Pure Centre Detox & Cleanse? (max. 40 characters - name cannot be changed without additional charges)* This field is required.
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How do you want to sign off your emails? Examples: Yours in Health, Dr. Jane or Be Well, Dr. Jane Smith?* This field is required.
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Please attach a high resolution version of your logo (preferably PNG with a transparent background):* This field is required.To be used on customized landing page
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Please attach a high resolution photograph of yourself:* This field is required.To be used on customized landing page
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Please provide us with a 1-2 paragraph biography to be added to your custom landing page. Include how you would like your name and credentials to appear at the top of your bio (ie. Dr. Jane Doe, ND):* This field is required.
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We require access to your Email Marketing Software (Active Campaign, Keap, Mailchimp, etc.) to set up your custom program's nurturing email sequence. PLEASE ensure that your software has automation series capabilities and provide us with all relevant information below (including name of the software, username, password and any specific login links):* This field is required.If using Active Campaign we require your Username, Password and Active Campaign Hosted Link. If using Mailchimp we require Username & Password. We also ask that you disable two-step verification for the time being. If you do not feel comfortable/aren't sure how we contact you via text message to determine what time is best to trigger the verification code via mobile. Take note that the STANDARD plan is needed to program automation series. Please upgrade your plan if you currently have the free or essentials version. * Don't have an Email Marketing Software? We strongly suggest Active Campaign!
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Please provide us with your Well World username and password (https://landingpage.designsforhealth.com/wellworld). If you are not signed up for Well World yet, you will first need to sign up as a practitioner with Designs For Health (www.designsforhealth.com or https://wellworld.designsforhealth.ca/embody/signup/index?plan_id=free-dfh-plan):* This field is required.Note: Please ensure that you are logged out of your Well World account in order to allow us access. You may receive emails from Well World as we set up your plan. This is us testing things, please disregard these emails until we fully deliver your program. Have you worked with Well World/Designs for Health to create your own app or white-labeled supplements? Please let us know!
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Do you have any special requests or comments before we start building your program?Now is your chance to request changes to the supplements used should you have any specific ones in mind.
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