Telehealth Consult Form (AZ, CA, FL, TX)
*COVID treatment and COVID prep kits available in all 50 states* Please fill out the following questions to the best of your ability. The more information provided the more value we can bring during your consultation. All communications from my team and me are provided for educational and informational purposes only and does not constitute providing medical advice or professional services.
Full Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
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Month
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Day
Year
Date
Contact Number
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Format: (000) 000-0000.
Email Address
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Instagram account
Check the conditions that apply to you or any member of your immediate relatives:
Asthma
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Cardiac disease
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Psychiatric disorder
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Check the symptoms that you're currently experiencing:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
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Neurological
Psychiatric
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Genitourinary
Weight gain
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Musculoskeletal
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Are you currently taking any medication or supplementation?
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Health issues you need help with:
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Current problem
Previous problem
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Pricing and time preferences
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Please Select
Consult with Dr. Barke 1/2 hour $375
Consult with Dr. Barke 1 hour $600
Anything else we should know about you?
Half hour with Dr. Barke $375 or One hour with Dr. Barke $600
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