Register

Health Care Provider Registration

Register to purchase ProLon or to make it available for your patients. Once you are registered, you will receive your HCP approval code which allows you to

1) Buy ProLon online from the Order page and make it available directly from your clinic to your patients or
2) Give the code to your patients as your approval for them to order and use ProLon when they place their online order for ProLon.

If you have any questions or do not receive your HCP approval code, please contact us at: 323.580.6855 or customerservice@prolonfmd.com.
Name*
First Last
Practice Name*
License No.*
Specialty*
Phone*
Email*
Enter Email Confirm Email

Account Manager*
How did you hear about us?*
Tradeshow*
Other*
Tradeshow Other*
Office Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Affiliate ID
Affiliate id for IS

To complete your registration and finish setting up your HCP account, you must read, review, and sign the following agreement. A full copy of this agreement and the ProLon® Health Care Professional Full Product Information packet will also be emailed to you for your records.

L-Nutra is proud to offer you (“HCP”) and your patients ProLon®. In exchange for L-Nutra providing you a HCP Code and providing you ProLon® for use in your practice (“Practice”), you agree that your registration as a HCP and the sale of ProLon® is subject to the following terms and conditions:

Use of ProLon® Responsibilities

Use of the ProLon Product. HCP understands that ProLon® is marketed as a conventional food and not approved by the U.S. Food and Drug Administration for the treatment of any disease or condition. HCP acknowledges and agrees that ProLon® should not be relied upon as a treatment for any disease or medical condition, and that Patients should not be advised that it may be so relied upon. HCP also acknowledges and agrees that it is his/her sole responsibility, prior to the sale or recommendation of ProLon® to any Patient, and prior to authorizing ProLon® to be furnished to any Patient by an outside supplier (including, but not limited to, L-Nutra), to establish that the Patient has obtained medical clearance from HCP or another licensed physician or other qualified health care professional that the Patient’s use of ProLon® is appropriate in light of the Patient’s individual health profile and the nature of ProLon® as a low-calorie diet.

Disclosure to Patients. HCP acknowledges receipt of and that he/she has reviewed the contents of the ProLon® Health Care Professional Full Product Information Packet. HCP agrees to advise each Patient of the information contained in the ProLon® Health Care Professional Full Product Information Packet including but not limited to the precautions and potential side effects of a low-calorie diet listed therein. HCP also acknowledges and agrees that it is his/her sole duty, and not that of L-Nutra, to provide the Patient with all necessary information regarding use of ProLon®.

Medical Supervision. HCP acknowledges and agree that that it is his/her sole responsibility to conduct a full and thorough medical evaluation of the Patient prior to the recommendation or authorization for sale of ProLon® to the Patient. Should a Patient have any known medical condition, HCP will authorize use of ProLon™ only if medically appropriate and only if under the supervision of himself/herself as a licensed HCP or that of a physician or other qualified HCP. HCP also acknowledges and agrees that L-Nutra is neither qualified nor has a duty to supervise a Patient’s use of ProLon® or independently confirm whether any Patient has been advised to have, or has actually received, a physical examination or medical clearance prior to the sale of ProLon® to the Patient by HCP. HCP understand that he/she, as a licensed health care professional, or another qualified, licensed health care practitioner, are the only persons qualified to determine whether the use of ProLon® is medically appropriate for any given Patient, and as such has the ultimate duty and responsibility to make this determination.

Professional Responsibilities

Licenses/Maintenance of Licenses. HCP represents and warrants to L-Nutra that he/she is a health care professional with the below-referenced professional license or registration, as applicable, and is in good standing in the state where he/she intends to offer ProLon® to individuals who seek his/her professional services. During the Term of this Agreement, HCP shall maintain in good standing all licenses, consents, certifications, accreditations and approvals necessary to conduct the Practice and provide health care services including the providing of ProLon® to Patients as a licensed HCP.

Compliance with Laws. HCP shall conduct the Practice in accordance with any and all applicable laws, rules, guidelines and requirements of governmental, accrediting, reimbursement, payment, documentation, and other agencies having jurisdiction over the operation of the Practice and the providing of ProLon® to Patients HCP and its agents, employees or staff have not and shall not engage in any conduct that violates any applicable health care laws and/or regulations including but not limited to the unauthorized or medically inappropriate providing of the ProLon® product to Patients.

Indemnification

HCP agrees to indemnify, defend, and hold harmless L-Nutra and its directors, officers, employees, agents, and affiliates from and against any and all actions, proceedings, claims, lawsuits, disputes, costs and expenses (including attorneys’ fees and costs), judgments, investigations, damages, fines, losses, settlements, and liability whatsoever, whether or not involving a third party claim, which arise out of or relate to the failure, or alleged failure, of HCP to comply with the requirements of this Agreement.

NOTWITHSTANDING ANYTHING TO THE CONTRARY CONTAINED HEREIN, TO THE MAXIMUM EXTENT PERMITTED BY LAW, L-NUTRA SHALL NOT BE RESPONSIBLE FOR ANY INCIDENTAL, CONSEQUENTIAL, INDIRECT, SPECIAL, PUNITIVE, OR EXEMPLARY DAMAGES OF ANY KIND, INCLUDING DAMAGES FOR LOST GOODWILL, LOST PROFITS, LOST BUSINESS OR OTHER INDIRECT ECONOMIC DAMAGES, WHETHER SUCH CLAIM IS BASED ON CONTRACT, NEGLIGENCE, TORT (INCLUDING STRICT LIABILITY) OR OTHER LEGAL THEORY, AS A RESULT OF A BREACH OF ANY TERM OF THIS AGREEMENT, AND REGARDLESS OF WHETHER L-NUTRA WAS ADVISED OR HAD REASON TO KNOW OF THE POSSIBILITY OF SUCH DAMAGES IN ADVANCE.

Term & Termination

The term of this Agreement shall be for a period of one (1) year and shall commence on the date of execution. Thereafter, the term of this Agreement shall automatically renew for successive one (1) year periods unless earlier terminated by the parties in accordance with this Agreement. This Agreement may be terminated at any time upon the written mutual consent of the parties. Death or total disability of HCP shall be deemed to be a Mutual Termination. L-Nutra may terminate this Agreement at any time by giving written notice via certified mail.

HCP acknowledges and agrees that the statements and representations made in this Agreement apply to each and every purchase of ProLon® that he/she makes or authorizes for each Patient.

Additional Terms

Choice of Law & Venue. This Agreement shall be construed in accordance with and governed by the internal laws of the State of California, except choice of law rules that would require the application of the laws of any other jurisdiction. The parties agree that the County of Los Angeles, California shall be the only proper venue for disputes related to this Agreement.

Waiver, Modification and Amendment. No provision of this Agreement may be waived unless in writing signed by all Parties hereto. Waiver of any one provision shall not be deemed to be a waiver of any other provision hereof. This Agreement may not be altered, amended or otherwise changed or modified, except in writing signed by both of the Parties.

Severability. If any part of this Agreement is void or otherwise invalid and hence, unenforceable, such invalid or void portion shall be deemed to be separate and severable from the balance of this Agreement, which shall be given full force and effect as though the void or invalid provision had never been a part of this Agreement.

Counterparts and Signatures. This Agreement may be executed in one or more counterparts, each of which shall be deemed to be an original, but all of which together shall constitute one and the same instrument. An electronic, facsimile, or photocopy copy shall be as effective as a signed original. Electronic, telecopied, and scanned email signatures shall be deemed originals.

AGREED & ACCEPTED

By: {Name (First):1.3} {Name (Last):1.6}

License Number: {License No.:2}

Date: 05/27/2018
User Role
Password
Enter Password Confirm Password

Register

Health Care Provider Registration

L-NUTRA

PH: 323.580.6855

HEALTH CARE PROVIDERS

DISCLAIMER

COMPANY

Register

Health Care Provider Registration

L-NUTRA

PH: 323.580.6855

HEALTH CARE PROVIDERS

DISCLAIMER

COMPANY

Thank you