Consultation Intake Form

1. SELECT YOUR CONSULTATION

Simple Consultation — $75

Basic Consultation — $350

In-Depth Consultation — $950

Total price: $950
50% booking deposit: $475
Remaining balance: $475

Form preview only. Personal and health information entry is locked until privacy safeguards are approved and tested. No information can be submitted, no payment is taken, and no appointment is booked.

2. CONTACT & REASON FOR VISIT — ALL CONSULTATIONS

Full name

Date

Phone

Preferred contact

Phone

Appointment

Virtual

In person

In one or two sentences, what would you like to discuss?

3. HEALTH & LIFESTYLE — BASIC AND IN-DEPTH ONLY

Age

Height

Weight (optional)

What are your primary wellness goals?

Current health concerns or diagnosed conditions (if any)

Medications, supplements or treatments (or write "none")

Typical meals and beverages (or attach a three-day food record)

Approximate daily water intake

Bowel movements per day/week

Typical activity, sleep, and other lifestyle habits

Three-day food record

4. ADDITIONAL BACKGROUND — IN-DEPTH ONLY

Are you currently receiving care from a licensed healthcare professional?

Yes

Significant medical history, procedures, allergies, or other information you wish to share:

What questions would you most like addressed?

This service provides wellness education and does not replace diagnosis, emergency care, or treatment by a licensed medical professional. Do not change prescribed treatments without consulting your treating clinician.

Submit completed health information only through the secure website intake process, not ordinary email. Privacy wording and final questions require Dr. Franco's approval.