Patient Forms

New Patient FormThese forms are necessary for both new and returning patients who would like to be evaluated at the clinic. The following documents must be reviewed and completed.

Authorization for Services– Complete your name, address, phone number, who referred you, etc.

Privacy Form – Privacy policy information for you to sign and date in acknowledgement.

Build a Better You Wellness Evalutation—B.A.B.Y

The BABY program is designed for new or returning participants who would like to be evaluated, report sent by mail, and consults over the phone which can be recorded at not additional cost. The following five (5) documents are included in the Build a Better You and must be received and completed before your report can be evaluated.

  1. Authorization for Services– Complete your name, address, phone number, etc. and sign and date form to accept terms for report evaluation.
  2. Current Supplement List– List all Vitamins and Minerals that you are currently taking each day.
  3. Lifestyle and Symptom Survey – Answer questions that allow Dr. Brouse to quickly and concisely capture your current symptoms and health history.
  4. 7 Day Diet Summary– Summarize your food intake for seven days.  This can be done the week before, during or after your blood draw.
  5. Monthly Nutrition and Lifestyle Log – A concise form that allows you to keep track of the most important aspects of your program and track your progress.

Adobe Reader – Get your free copy of Adobe Acrobat Reader!  We post our downloadable documents as Acrobat files. If you do not have Acrobat, download it now so you can view and print our supplement order forms, Audio/Video order forms, educational brochures, flyers, booklets and newsletters.

Contact US

If you have not had a consult with Dr. Brouse before, please visit New Patients Page.
Fill out the NAI form and follow instructions per the instruction.

If you have additional questions, call the clinic at 503-631-4184 to speak with a staff member.

Need more information? Have questions? Contact Us!

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