enjoy life foods - patient starter kit request form

patient starter kit request form

Simply fill in the required information below to receive your Food Allergy and Intolerance Patient Starter Kit. In this kit, you will receive helpful product information, coupons and educational materials for your patients, as well as an opportunity to request further materials and samples.

If you have all ready requested a Patient Starter Kit and would like to request more materials, please fill out the Healthcare Practitioner Request Form.

Required fields marked with a *
First Name: *
Last Name: *
Business:
Address 1: *
Address 2:
City: *
State/Province: *
Zip/Postal Code: *
Country: *
Phone:
Email Address: *

We'd love to know a little bit more about you and your practice. Please take just a few more minutes to complete this brief survey. Thanks in advance, we really appreciate it!

1.	Which of the following best describes your credentials?
	M.D. D.O. N.D. R.D. R.N. Other (please specify)
2.	Which of the following issues do you address in your practice? (select all that apply)*
	Food avoidance for allergies Food avoidance for intolerances Gluten-Free diet for Celiac Disease Gluten-Free/Casein-Free diet for Autism Food avoidance for other health conditions (please list below)
3.	Which demographic best describes your patient population? (select one)
	Pediatric Adolescent Adult All of the Above
4.	How many patients with food allergies and intolerances do you expect to see in the next 3 months? (select one)*
	5 or fewer 6-25 26-100 Over 100
5.	Are you familiar with Enjoy Life products? (select one)
	Yes No Not sure
6.	If you are familiar with Enjoy Life, how did you hear about us? (select all that apply)
	AANP Directory Colleague Patient Enjoy Life representative DAN Conference ADA/FNCE Show AANP Conference AAEM Conference Natural Products EXPO Celiac Conference Food Allergy Conference	Today’s Dietician Allergic Living Gluten Free Living Kiwi Living Without Mothering Website ad Blog posting Saw it in the store Not sure Other (please be specific)
7.	Would you like to join our mailing list to receive new product and store announcements, tasty recipes and more! Don't worry we won't clog up your inbox or share/sell your personal information.
	Yes No
8.	What "allergen-free" food product would you most like to have available for your patients? We'd love to hear your ideas!**

** Enjoy Life welcomes everyone's opinions about our foods and suggestions for future new products. However, we have to let you know that all comments, suggestions, ideas, concepts or recipes offered to us through this website are deemed and shall remain the property of Enjoy Life Natural Brands, LLC.