Intake Form for Genetic Information We use for genetic information for testing and consulting. This form is only for use if you're interested in working with Dr. Turner on your genetic information. Name* First Middle Last Date of Birth* MM slash DD slash YYYY Age*Sex* Female Male Weight*Height* Primary Phone*My Primary Phone is a...* Cell Phone House Phone Office Phone Best time to call?* Secondary PhoneMy Secondary Phone is a... Cell Phone House Phone Office Phone Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* Skype ID Occupation* Please List your health concerns in order of importance. Press the "+" to add a concern.List of Health Concerns* Important Information Payment is due at the time of service. We do not accept any type of insurance. We accept: Cash, Check, Debit Cards, and all major Credit Cards. If you cancel an appointment with less than 48 hours’ notice, or fail to make the scheduled time, you will be charged the full appointment fee. Payment In order to proceed with setting up your Genetic account my assistant will need to have payment. The cost for a full DNA test that then becomes data to be interpreted by Dr. Turner costs $199. Directions to access your account and a kit to collect your saliva for DNA testing will be sent to you. If you already have your DNA data (23 and ME is fine if it is before August 2017). Then a $25 dollar charge will set up your account and you can upload the data from that test. Once your data has been uploaded, this site will produce details around your data that will be able to be used for your consultation and your health care. There will be different charges for each consultation based on length of time. These consultations with Dr. Turner can be done face to face or via skype, zoom, facetime or other electronic connection. Please review the video (https://vimeo.com/user20863995/review/137064917/bd14c94e08) prior to your consultation so more information can get covered. What are your goals for this consultation?*I'm Interested In....*Please check the following that apply to you. Purchasing a Your Genomic Resource™ DNA Test Kit Using 23andMe Data for Analysis A one-time consultation to learn about my genetics A one-time consultation to learn about nutritional support Becoming a long-term client and scheduling regular follow-up visits Making dietary changes I'd like my consultation to be...* via Phone via Skype in person Additional QuestionsOn a scale of 1-5 how complicated do you feel your case is?* 1 - easy 2 - somewhat easy 3 - neutral 4 - somewhat difficulty 5 - very difficult How much of a priority are your health concerns in your life?* 1 - not a priority 2 - a low priority 3 - a medium priority 4 - a high priority 5 - a very high priority What is your level of commitment to utilizing the recommendations?* 1 - not very committed 2 - a little committed 3 - neutral 4 - commited 5 - very committed Do you see any other alternative or complementary practitioners or doctors?* Yes No If yes, do you think they will be supportive of our recommendations? Yes No Not Sure Additional Instructions Your next step is to press submit below. This will submit the intake form. Then, call to schedule a consultation. Initial consultation fee is $150. Watch this video to prepare for your visit, it provides an excellent introduction on the basics of genetics: https://vimeo.com/user20863995/review/137064917/bd14c94e08 Checklist: Watch the video on the Basics of Genetics Set up your Client Portal (Instructions will be emailed separately) Complete the Symptom Survey and Consent Form in your Client Portal. Review your Genetic Variant Nutritional Assessment Report Genetic Variant Nutritional Assessment Report: The Functional Genomic AnalysisTM software creates an individualized Genetic Variant Nutritional Assessment Report based on your genetic data. A Symptom Survey will be provided through your client portal for you to complete. This combines your symptoms with your DNA for analysis. Supplements and dietary changes are recommended based on your genetic test results Need Help? If you have questions or need to discuss further -please contact Torie Foote (Dr Turner’s assistant) at [email protected] PhoneThis field is for validation purposes and should be left unchanged. Δ