New Client Form

Evan Brand, BCHN, FNTP

Website: evanbrand.com | Email: Office@EvanBrand.com
Dear Client,

Welcome! And thank you for choosing Evan Brand Functional Medicine Clinic to help you.

HOW THE PROCESS WORKS:

STEP 1:

During your initial consultation (i.e. New Client Consultation), one of our practitioners will review your health history and make recommendations for lab tests that are appropriate for your age, sex, and health history. If you already have test results to review, they will also be reviewed and a protocol may be created for you.

STEP 2:

Once you have completed your lab tests, our practitioner will explain the meaning of your test results to you in a follow-up consultation. Our practitioner will create recommendations for you including diet changes, nutritional supplements, and exercise, lifestyle, and stress management advice.

STEP 3:

Subsequent consults are scheduled to monitor your progress.

We invite you to contact us via email should you have any questions during the course of your journey.

We look forward to helping you in achieving your current wellness goals, and to guiding you in maintaining wellness throughout your life.

In Health,

Evan Brand, BCHN, FNTP, and The Wellness Team

Important

Our Practitioners: Mr. Evan Brand, BCHN, FNTP and Ms. Tamy Anderson, FDN-P
- Our practitioners do not treat or diagnose any disease. Our practitioners' work is to help support physical and chemical stress imbalances, with the goal of promoting wellness. Consulting with our practitioners does NOT create a “doctor-patient” relationship and they are not “treating” you.
- Because your case may be a valuable education for other clients and practitioners, we may use your lab test results and protocol to teach others in functional medicine in the form of a case study. Your personal information such as address, email, and phone number will not be shared. We would just show video content about biomarkers, protocols, solutions, etc.
New Client Paperwork

I clearly understand and agree that all services rendered to me are charged directly to me and that I am responsible for payment. I also understand that if I suspend or terminate my protocol, any fees for professional services rendered to me will be immediately due and payable. If a card is on file, it will be charged to get your due payment to a zero balance. I authorize Mr. Evan Brand and his team to release my personal health information to me.
Full Name Regarding Services*

First NameLast Name
(If client is a minor) Name of Parent/Guardian

First NameLast Name
Date Today

MonthDayYear

Supplements, Food, and Rx Drugs Info
(List all brands and amounts) Are you currently taking any vitamins/minerals/herbs/remedies/prescription meds/other drugs or supplements?
Also, what is the purpose of each drug or supplement?
Have you ever been or are currently a vegetarian or vegan? IF SO, how long?
List your normal breakfast, lunch and dinner
Any known allergies to medications or herbs?
What are the three worst foods you eat each week?
What are the three healthiest foods you eat each week?
What percent of your diet is Organic?
How is your energy level?
Do you have and use WiFi? If so where is the router located?
Do you turn off WiFi at night? Or have you turned down the power output settings?
Do you use and/or sleep with a fitbit, apple watch, or other wearable EMF-emitting technology?
How often/long do you talk on a cell phone? Do you put the phone directly to your head?
Do you have technology in your bedroom? (Cell phones under your pillow, alarm clocks near your head, use laptop in bed, etc?) Explain...
Do you have fun in life?
What kind of music do you listen to? (A favorite go-to song, album, or artist?)
Do you beat yourself up mentally with negative self-talk?
Do you have TMJ or grind your teeth while you sleep?
Do you feel your libido is adequate?
Do you enjoy daily activities?
Do you feel apathetic or complacent about previously enjoyed sports, hobbies, clubs, games, etc?
Do you notice feeling more agitated/irritable than previously?

Health Priority Form

Please list the 5 major health concerns in your order of importance
1.
2.
3.
4.
5.
NOTE: If there is any information that you feel is important for us to know that is not in your intake form, we kindly request that the relevant details be sent in a concise and organized format (Word Document or PDF) to office@evanbrand.com.

Policies and Procedures

First Appointment

Your first consultation will be 30 minutes-1 hour. During this time one of our practitioners will determine appropriate lab tests you should order to address your specific health concerns.

Fee Schedule:

New client initial consultation with Mr. Evan Brand, BCHN, FNTP: $799

New client initial consultation with Ms. Tamy Anderson, FDN-P: $499

Follow-up consultation with Ms. Tamy Anderson, FDN-P:

1-10 min: $225
11-30 min: $325
31-45 min: $375
46-60 min: $425
- Payment is due at the time of consultation
- Methods of payment are eCheck, Visa, MasterCard, or American Express.
- All consultations are time recorded from the time the appointment begins; you will only be billed for the actual time used. If you cancel your appointment with less than 48 hours notice you will be charged for the time booked.
Appointments

Follow-up consults may be scheduled in blocks of time. We encourage you to book your appointments 1-3 weeks in advance. You will receive a reminder via email.

Lab Tests

The results of your lab test(s) will be sent to our office 2 to 4 weeks after mailing your specimens to the lab. You will be emailed to schedule a follow-up appointment. We do not use insurance and there are no returns on lab tests.

International Lab Testing

If you are outside the USA, extra shipping charges may apply for your test kits. If labs are sourced from outside us, there will be a $199 per lab kit read fee.
WELLNESS SUPPORT WITH EVAN BRAND FUNCTIONAL MEDICINE CLINIC:

Our practitioners do not treat or diagnose any disease. Their work is to help support physical and chemical stress imbalances, with the goal of promoting wellness. Consulting with any of our practitioners does NOT create a “doctor-patient” relationship and they are not “treating” you.

Clients who are seen via phone or virtual mediums like Zoom, need to realize there are physical limitations of not seeing someone in person. Due to these physical limitations, it’s important that a client has seen their primary care physician within the last year in person to rule out any disease pathologies as well as assess any health issues that may be limited via a virtual setting.

During new client consultations, you will not receive a comprehensive health plan. Laboratory assessments will be required and recommended during this initial consultation to investigate your health concerns.

CANCELLATION POLICY:

If you are unable to keep your scheduled appointment, please notify our office a minimum of 48 hours before your scheduled time or you may be charged for that appointment. New Client Consultations may be charged in full if the cancellation policy is not followed. We have clients waiting a month/s to be seen, and a missed appointment takes time away from someone else.

If the practitioner is running late you must be available for the entire time of the consult. Our practitioners may be running late with his previous client, you will be charged a missed consult fee equal to the value of the consult if you are not available.

There are no refunds for consultations.

A full list of policies and procedures and the full disclaimer can be found at https://www.evanbrand.com/faq/ and https://evanbrand.com/terms . Our rates and policies are subject to change without prior notice. Please refer back to the website to stay up to date on any policy changes.
Type your full name to agree to the terms and conditions (client or parent/guardian)*
(CLICK AND HOLD YOUR MOUSE) to Sign here to confirm fee schedule and all policies:*

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UPLOAD any Lab Testing you've had run in the last 6 months you want Evan to review: (you can also email later to office@evanbrand.com)

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Supplements, Food, and Rx Drugs Info

Health Priority Form