Application for Designation as a Therapeutic
Lifestyle Changes (TLC) Center of Excellence

I. Requesting Healthcare Provider or Medical Center
Name of requesting healthcare provider or medical center:
Name and title of contact person:
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Fax:
Email:
II. Qualifying Factors for Designation of TLC Centers of Excellence (please check those that apply to your center)
Licensed healthcare provider on staff (e.g., MD, DO, DC, LAc, RD, RN)
Healthcare provider is required to be Firstline Therapy® (FLT) Certified
FLT trained staff that conducts independent consultations using the FLT program and protocols
Web site and online ordering access (Meta-eHealth™ Web site or other)
Clean and professional facility
Comply with federal, state/provincial, and local laws
Please provide a brief overview of your center and any new initiatives underway.
III. Approval by Authorized Healthcare Provider
Name and title:

Please check this box indicating that you are an authorized healthcare provider

Note: Submission of this application does not guarantee acceptance. If accepted, the center will need to submit a signed license agreement for use of TLC Centers of Excellence intellectual property and receive secure approval by the TLC Centers of Excellence Advisory Board before the official designation is awarded.

FirstLine Therapy® is a registered trademark of Metagenics, Inc.