CIOFM Discovery Call Application
This application is designed to help us understand your goals and determine if our practice is a good fit for you. Please answer the following questions to the best of your ability. 

Your answers will also help our team address your specific questions and concerns, making the most of your 20 minute call time. Please remember this call does not establish a patient relationship nor can anyone  you speak with at this phase give you specific advice about your case. 

There is a $100.00 charge for Discovery Calls which will be credited to the price of your initial consultation package fee if you decide to move forward with treatment through CIOFM.

We move pretty fast around here! Dr. Jamie will review your application within 48 hours. Once reviewed our team will reach out via email to schedule your Discovery Call with our one of our nurses. Be sure to check your spam folder for that first correspondence from our team. 
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First and Last Name *
Phone Number *
Email  *
What inspired you to apply for the Discovery Call? Why do you think a comprehensive, root based, holistic membership program might be right for your anti-cancer strategy?
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What are the top three questions about our practice and program you would like to have answered during your Discovery Call with our team?
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All patients must be able to travel to our clinic in Blue Ash, OH regularly or intermittently to be seen in person by our care team. Are you willing and able to travel to the clinic to receive care?
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Required
Are you wanting help with active cancer, concerns regarding recurrence of previously treated cancer, or trying to lessen your risk of developing cancer because of genetic testing or a family history?
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Have you ever seen a holistic physician or Functional Medicine doctor?
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What do you think your BIGGEST OBSTACLE(S) might be for achieving your goals within our program?
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If you are seeking help with active cancer, do you currently have an oncologist?
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What is your diagnosis or what cancers have you had in the past?
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Date of diagnosis and stage (if known). 
During the Discovery Call, our team prefers to spend the time understanding you and your goals. 

Please take the time to learn about the details of the service process by visiting our website to read the New Patient Information and Membership Information prior to submitting this application.  *
DEPOSIT, PAYMENT and REFUND INFORMATION for the Initial Consultation Package:

There is a $100 fee for the Discovery Call that will be credited to your initial consultation if you decide to proceed with treatment at CIOFM. This fee must be paid prior to scheduling your Discovery Call.  

The initial consultation package is TWO appointments with Dr. Jamie and ONE session with our oncology dietitian, Sarah Heffron. 

The total for the package is $2,900.00. 

A 50% deposit is due (minus the cost of the Discovery Call) when you book your first appointment and the balance is due on the date of your first appointment with Dr. Jamie.

Discovery Call $100.00
Deposit $1,400.00
Balance $1,400.00  

If you cancel your first appointment, $300.00 of your deposit is non-refundable due to the amount of work our team completes prior to your first appointment. 

No payment is collected at the second appointment. If you cancel your second appointment with Dr. Jamie, no refund is offered due to the extensive amount of work we have done on your case by that point. 

If you keep a card on file, that is the one we will use to remit payment unless you instruct us otherwise. 
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CIOFM is a membership based practice. Our Initial Consultation Package foundational and is designed to prepare you for and lead you to a practice membership. 

Membership is a 12-month commitment that allows us the time to understand and potentially heal the root cause of the cancering process in your body. 

It will require additional functional medicine testing, nutrient testing, toxicity testing, additional and/or repeated bloodwork, and a personalized treatment plan recommending multiple modalities. 

The cost of these tests and treatments is in addition to any fees for consultation or membership and can be a significant investment. We do not file insurance and insurance typically does not cover integrative care. 

Transparency on the cost of this level of care is important, and we want you to make an informed choice on your potential investment.

An estimate of these costs could look like this:

$1,099.00 per month for membership

$600.00 - $1,200.00 per month for supplements, homeopathy, and/or repurposed drugs protocols.

$3,000.00 - $10,000.00 per year in functional testing and bloodwork. 

$40,000.00 - $80,000.00 for your first 8-12 week multi-modality Intensive Outpatient Treatment Plan to receive care at our clinic in Blue Ash. 

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Integrative Oncology care in our program requires a significant mind, body and spirit personal commitment to healing.

Your treatment plan will involve learning about your body, building new habits around nutrition, movement, sleep, and mindset, and maintaining consistent communication with your care team.

How ready and able are you to make this time, energy, and resource commitment, including an intensive treatment plan, daily supplements, regular appointments, and working with our holistic dietitian and health coach as part of your care process?

1 = Not Ready
5 = Very Ready

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Are you comfortable communicating via email, medical portal messaging, and Zoom meetings?
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What is your zip code?
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What is your date of birth?
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How did you hear about our practice?
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