Provider Referral

Please fill in the form below. This form is HIPPA complaint.
Patients Name*

First NameMiddle NameLast Name
Patients DOB

MonthDayYear
Date
Phone Number

Area CodePhone Number
Please list conditions and diagnosis
Current Medications
Allergies
Date of Recent Labs Ordered *

MonthDayYear
Date
Special Considerations
Primary Care Physician or Mental Health Provider Information:
PCP/MHP Name

First NameLast Name
Practice Name
Practice Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
PCP/MHP Phone #

Area CodePhone Number
Fax
Ketamine Referral

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 Quad Cities Ketamine Clinic regarding the treatment of my patient.
Provider Signature*

Clear
Provider Signature (Typed)*

First NameLast Name
Date*

MonthDayYear
Date
Time

:HourMinutesAM/PM Option
Should be Empty:

Primary Care Physician or Mental Health Provider Information: