VIP Referral Application Functional Medicine Care with Dr Jarrod Cooper-ND This application is reserved for patients referred by existing patients or trusted practitioners. Referred applications are reviewed as a priority. Who referred you?(Required)How do you know them?First Name(Required)Surname(Required)Email Address(Required) Mobile Number(Required)Country / Time Zone(Required)AgeWhich program are you interested in? Functional Medicine Case Review – 3 Months ($4,500 AUD) Comprehensive Functional Medicine Care – 6 Months ($7,500 AUD) Advanced Functional Medicine Care – 12 Months ($12,500 AUD) Not sure – happy to be guided Please briefly describe your main health concerns and how long they have been present(Required)Have you completed any functional or advanced testing previously? (Select all that apply)(Required) Comprehensive stool testing (GI-MAP or similar) Hormone testing (DUTCH or similar) Organic Acids Test (OAT) Extensive blood testing None of the above Please confirm the following:(Required) I understand this is program-based functional medicine care, not a single consultation, and that program fees range from$4,500–$12,500 AUD, excluding testing and supplements.
