New Client Paperwork

Kris Dorner, CFMP

Email: office@krisdorner.com
Dear Client,

Welcome! And thank you for choosing Kris Dorner to help you.

HOW THE PROCESS WORKS:

STEP 1:

During your initial consultation, Kris will review your health history and make recommendations for lab tests that are appropriate for your age, sex and health history.

STEP 2:

Once you have completed your lab tests, Kris will explain the meaning of your test results to you in a follow-up consultation. He 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.

Kris does not treat or diagnose any disease. Kris' work is to help support physical and chemical stress imbalances, with the goal of promoting wellness. Consulting with Kris does NOT create a “doctor-patient” relationship and he is not “treating” you.

In Health,

Kris Dorner, CFMP
Full Name Regarding Services*

First NameLast Name

Do you use tobacco?
(If so, how much and often?)
Do you use cannabis? Let me know what form (edibles, flower, tincture, vaporizer, etc) and how it helps you?
What kind of water do you drink? (Spring water, tap water, bottled water what brand, Fridge filter, Berkey, etc)
Have you lived where you drank well water? IF so, when and where?
Do you live in a new home build or somewhere with new carpet, new cabinets, new paint, etc?
What is your relationship to plastic? Drink from plastic water bottles, use plastic Tupperware, etc?
Do you use any products with synthetic fragrances (scented garbage bags, dryer sheets, fabric softeners, laundry detergent, dish soap, hand soap, air freshener, cologne, perfume, candles, anything else scented...)? WHICH ones?
Have you had any exposure to man-made chemicals that you know of (vaccines, cleaning chemicals, toxic metals, farm chemicals, hair care products, insecticides, paints and solvents, auto chemicals, welding, etc)? Please explain:
What is your history with having cats as pets, lice, ticks, fleas, etc.?
Have you tested positive or suspected you've had covid?

YesNo
Covid vax?

YesNo
Do you have carpet in your house? If YES, where?
Do you have a gas furnace or stove/oven?
Have you had a mold issue before?
Have you ever had water damage in your current living location?
Do you have implants (silicone or other)?
Have you had your wisdom teeth removed?
Do you have amalgam (silver) fillings?

YesNo
Do you drink soda (diet or regular)?
(If so, how much and often?)
Do you drink caffeinated drinks?
(If so, how much and often?)
Do you drink alcohol?
(If so, how much and often?)
How much water do you drink per day?
What role does exercise play in your life?
Currently are you bothered by any exposures like chemicals, fumes, cigarette smoke, perfumes, car exhaust, etc? Please explain:
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:

	Health Concern
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 to office@krisdorner.com.

Policies and Procedures

First Appointment

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

Fee Schedule:

New client initial consultation with Kris, CFMP: $399

Follow-up consultation with Kris Dorner CFMP:

1-10: $149
11-30: $249
31-45: $299
46-60: $349
- Full Payment for the New Client Consultation is due at the time of scheduling.
- The New Client Consultation is non-refundable.
- Follow Up Consultation payments are due at the day/time of consultation.
- Methods of payment are eCheck, Visa, MasterCard or American Express.
- Follow-Up 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 may be charged the full rate.
- If payment is not made for a consultation within 10 days after the call, we will automatically charge you for that call and any services rendered.
*Prices are subject to change without prior notice.

Appointments

Follow-up consults may be scheduled in blocks of time. We encourage you to book your appointments 1-4 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. Kris will evaluate the results. After evaluation, you will be contacted to schedule a follow-up appointment. We do not use insurance and there are no returns on lab tests.

If recommended labs are sourced from outside our clinic, there will be a $99 lab read fee per lab test result.

International Lab Testing

If you are outside the USA, extra shipping charges may apply for your test kits.

WELLNESS SUPPORT WITH KRIS:

Kris does not treat or diagnose any disease. Kris' work is to help support physical and chemical stress imbalances, with the goal of promoting wellness. Consulting with Kris does NOT create a “doctor-patient” relationship and he is not “treating” you.

Clients are seen via phone or virtual mediums like skype or facetime, 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. Follow Up Consultations may be charged in full if the cancellation policy is not followed. Kris has clients waiting a month 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. The practitioner 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.krisdorner.com/faq and https://krisdorner.com/terms-conditions. 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:

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

NOTE: If you are uploading or sending a photo of a test result, please make sure the text is legible even when zoomed in.
Cancelof
Should be Empty:

Kris Dorner, CFMP

New Client Paperwork

Supplements, Food, and Rx Drugs Info

Health Priority Form