Ketamine North Referral Form

Provider Referral for Ketamine North Infusion Center

I am currently treating (patient name):

First NameLast Name

Birth Date

Date

Phone Number

Please enter a valid phone number.

Last visit with patient

Date

Please fax or email a copy of the patient medication list, along with your last visit with the patient so we can better assess their overall mental health history, and assist us in determining if ketamine would be a good option for them at this time.
Fax: 833-903-0315
Email: bewell@ketaminenorth.com

For (list conditions & diagnosis)

I feel that (check below) IV ketamine infusion therapy/SPRAVATO (esketamine- nasal spray)/TMS may benefit this patient and am referring him/her for evaluation as an adjunctive treatment for his/her diagnosis. I agree to collaborate with my patient’s Ketamine North/Psych North 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 (checked below) at www.Ketaminenorth.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.

Recommended Treatment*

IV ketamine infusion therapySPRAVATO (esketamine- nasal spray)TMS

Provider Signature and Date

Printed name

Provider Phone Number