P3 Health Referral Request

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    This Referral is for:

    Select a Doctor:

    *Referrals for Dr. Cook and Dr. Jacobson must come from a physician or nurse practitioner.*


    LYME Literate Complementary Healthcare Provider (select below):


    Naturopathic Medicine Osteopathy Nutritionist Genetic Testing Neuro Rehabilitation (PoNS)

    Referring Physician/ Nurse Practitioner

    Patient Information

    Reason for referral:


    Assessment and treatment of Lyme disease, MSIDS (Multiple Systems Infectious Disease Syndrome), Chronic Fatigue Syndrome/ Myalgic Encephalitis (ME), Exertional Intolerance Syndrome (EIS)



    Preventive Medicine



    Bioidentical Hormones


    Assessment and treatment of parasite


    Mold toxicity


    Heavy metal toxicity


    Fibromyalgia/Chronic Pain Syndrome


    Cognitive (decline and mental health)


    Autoimmune Thyroid dysfunction


    Cancer


    Thyroid dysfunction


    Microbiome Dysfunction/ Small Inetstinal Bacterial Overgrowth (SIBO)/ Irritable Bowel Syndrome (IBS)

    Please include a brief history of the patient’s symptoms:

    Labs Attached


    Previous blood and urine results


    Previous diagnostic imaging reports


    Public Health – Lyme


    Public Health – Lyme Co-infections


    Medication List


    Supplement List