Referral form
For health providers
Is your patient between 20 - 65?
*
Yes
No
Is your patient pregnant?
*
Yes
I'm not sure
No
Date of birth
*
-
Month
-
Day
Year
Date
Referrer name, occupation, and contact details:
*
Name, practice name, phone contact, email, etc.
Is your patient aware of this referral?
Yes
No
Patient full name
*
First Name
Last Name
Patient address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient NHI (if known):
Patient cell phone Number
*
-
Patient E-mail
*
Does your patient prefer remote consultation?
Yes
No
Unsure
History of presenting complaint:
*
Please contact Crisis Resolution Service if you have concerns about your patient's safety.
My patient has tried at least THREE medications with poor effect.
*
Yes
No
Why not?
*
Only tried fewer than three medications
I have never offered my patient three medications
Patient has poor tolerance
Patient prefer not to take traditional medications
List the medications you have tried:
*
Please tick the following conditions that applies to your patient:
Allergy to ketamine
Substance abuse
Bladder or kidney pathology (i.e. cystitis, hydronephrosis, CKD, etc.)
Intellectually disabled
Chronic hypertension
Psychosis or Schizophrenia
Please list other medical conditions (if any):
Submit
Should be Empty: