Provider Referral Form for Ketamine Infusion Therapy Order Number Patients Name * Patients DOB Phone * Please list conditions & diagnosis Current Medications: Allergies: Date of Recent Labs Ordered: * Special Considerations: Primary Care Physician or Mental Health Provider Information: PCP/MHP Name: Practice Name & Address: PCP/MHP Phone #: Fax: I 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) * Date/Time
