Patients Name(Required) Patients DOB(Required) MM slash DD slash YYYY Phone(Required)Please list conditions & diagnosisCurrent Medications Allergies Date of Recent Labs Ordered(Required) MM slash DD slash YYYY Special ConsiderationsPrimary Care Physician or Mental Health Provider InformationPCP/MHP Name Practice Name & Address PCP/MHP Phone #FaxI feel Ketamine infusion therapy may benefit this patient and am referring him/her for evaluation as an adjunctive treatment for his/her diagnosis. I agree to collaborate with Midwest Ketafusion regarding the treatment of my patient.Provider Signature (type name) *(Required) Date MM slash DD slash YYYY
