Physician Release

Ideal Protein Physician Release To Participate

Program Basis

The below named mutual patient is requesting to start the Ideal Protein Weight Loss Management Program which is monitored weekly in our office. We would like to have your medical clearance for him/her to start. Please provide your clearance responses below.

About Ideal Protein Program

0 Years
ago this protocol was developed
0 + million
dieters have been successful with it
health professionals across North America currently recommend the program

Ideal Protein Program Phases

  • The Ideal Protein Weight Loss Method consists of a three phase medically-designed protocol.
  • The first two phases focus on weight loss and also stabilization of blood sugar levels, blood pressure and other obesity related issues.
  • The last phase help the dieter maintain their weight loss and health achievements. This is not a high protein diet, it is a hypo-caloric low fat, low carbohydrate and adequate protein diet.


  • The patient will use a combination of their foods and Ideal Protein foods.
  • The protein isolate rich foods are non-GMO and have a very high biological value, are low in calories, low in fat and contain eight essential amino acids.

Our cooperation

  • Feel free to call us anytime regarding this patient or this program.
  • We have informed the patient that you, as their prescribing physician, will be monitoring pertinent vitals and medication(s)/dosage changes.
  • They are aware that if medication dosage changes must be made, they will be made entirely by you.
  • As progress occurs, we will encourage this patient to follow up with you regularly while on this program.

Physician Release Form

Physician Release to Participate

  • Patient’s info
    • Date Format: MM slash DD slash YYYY
  • Physician’s info
  • About patient’s health