Provider Referral Form

for Ketamine Infusion Therapy

In order to provide immediate care, we need the following information sent to us. Once we have the patient’s information, we will contact them and schedule their infusions.

Patient Information

Patient Full Name *

Patient DOB *

Patient Phone *

Patient Email *

Provider Information

Provider Name *

Phone Number *

Fax Number

Provider Email *

Currently Treating Patient For The Following: *

Upload Medical Records *

Last Eval Note + Any Relevant Medical Records

I feel that Ketamine infusion therapy may benefit this patient and am referring him/her for evaluation for Ketamine Infusion Therapy as an adjunctive treatment for his/her diagnosis. I agree to collaborate with my patient’s Ketamine provider regarding the treatment of my patient.

I acknowledge that I may contact my patient’s provider to discuss the treatment protocol and may review more information about this therapeutic option at ketamineclinicsouthflorida.com

I will continue to follow and direct the care of my patient during and after the completion of the course of therapy and if applicable, will coordinate his/her care with his/her primary care or psychiatric physician.

Provider Printed Name: *

Date Signed *

Provider Signature *

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Please complete this form along with your patient’s most recent H&P/Evaluation