Wellness Blueprint WDN Cleveland Heart Lab Panel

Wellness Blueprint Requisition Data Form

We are excited to welcome you to the upcoming Wellness Blueprint course at the Kois Center! Throughout the program, you will experience many of the same tests, screenings, and assessments that we recommend for patients while building your own personalized Wellness Blueprint. We look forward to sharing this experience with you and helping you gain a deeper understanding of how these concepts can be applied in clinical practice.


Prior to the course, we ask that you please complete the Wellness Blueprint Data Requisition Form using the form below. The information you provide allows our team to prepare and pre-fill the laboratory requisition forms required for the various tests and assessments that will be completed before and during the course. It also helps us organize your clinical information so everything is ready for your Wellness Blueprint experience.

For U.S-Based Participants

As a U.S.-based participant, you will complete your cardiovascular and inflammatory biomarker panel through Cleveland HeartLab at a local Quest Diagnostics laboratory before the course. Completing your bloodwork in advance allows us to have your results available during the lecture so you can better understand your personal health data and follow along as we review each biomarker.

 

Please complete this Data Requisition Form as soon as possible. Once we receive your information, we will send your Quest Diagnostics requisition along with instructions for completing your blood draw.

 

For International Participants

As an international participant, your cardiovascular and inflammatory biomarker panel will be completed during the Wellness Blueprint course at the Kois Center. Completing this form in advance allows us to prepare your laboratory and salivary diagnostic requisition forms before you arrive so your blood draw can be completed efficiently during the course.

 

 

Please complete this Data Requisition Form as soon as possible. Once we receive your information, we will prepare your laboratory and salivary diagnostic requisition forms for the onsite phlebotomist.

 

Wellness Blueprint Data Requisition Form

Wellness Blueprint Data Requisition

Please fill out the below form to submit the requested data to the Wellness Dentistry Network team. This information helps our team fill out your bloodwork requisition form and provides additional data for your health journals. 

Blood Biomarker Requisition Information

Below is the data requested by the blood draw companies to complete your requisition form. Please note that BMI does not need to be calculated if it is not known.

 

Since this blood test reviews inflammatory, lipid, metabolic, and nutritional biomarkers, we request that this be an 8-hour fasting blood draw. If you cannot fast due to specific conditions, please let our team know and we will take that information into account when we review the data. 

Requested Clinical Data

To assist us in creating a thorough health journal after the course's completion, we request that you send your most recent periodontal chart and bitewing radiographs. 

  • For your periodontal chart: Please ensure that it includes pocket depth, bleeding on probing, and recession, at a minimum.
  • For your radiographs: Please submit your bitewing radiographs and anterior PAs, at minimum. We request if you have bone loss that you submit vertical bitewings.

Acknowledgments

Please be aware that we will performing a variety of assessments and tests on you throughout your Wellness Blueprint course. Salivary diagnostic tests will be performed and there are certain timeframes we want to make you aware of to ensure the most accurate test is achieved. Please review the acknowledgements below.