Consultation Intake Form

1. SELECT YOUR CONSULTATION

Simple Consultation — $75

Basic Consultation — $350

In-Depth Consultation — $950

Total price: $75
50% booking deposit: $37.50
Remaining balance: $37.50

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?

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.