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