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Practitioner request

My patient is interested in taking the medical food KetoCitra for the daily dietary management of individuals with mild to moderate stages (CKD stages 1-3) of autosomal-dominant polycystic kidney disease (ADPKD).

Please contact them by phone at to provide a free sample for a month supply of KetoCitra.

Patient

Practitioner

Email to send sample code

PRACTITIONER REQUEST FORM:

I have my patient’s permission to provide their information to Santa Barbara Nutrients. I
recognize that no medical advice or information will be shared or discussed with my patient on behalf of
Santa Barbara Nutrients.

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Timestamp

Audit

September 24, 2021 12:16 pm PST

Practitioner request Uploaded by David Stagnitto - stagnitto@sbnutrients.com IP 24.213.151.4

October 6, 2021 1:08 pm PST

Document owner stagnitto@sbnutrients.com has handed over this document to practitioners@santabarbaranutrients.com 2021-10-06 13:08:21 - 24.213.151.4