Client 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.

Client Intake Form: Complete your name, address, phone number, who referred you, etc.

MetSys Wellness Evaluation

MetSys is designed for new or returning participants who would like to be evaluated. You will receive a personalized electronic report and schedule a report consult by phone which can be recorded at no additional cost. The following documents must be completed and returned before your report can be evaluated.

  1. Client Intake Form: 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. My Fitness pal – 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.

If you have additional questions, call Julie at 503-631-4184.

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