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


    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