Patient Ketamine & TMS Referral Form

What's This Referral For?

Physician / Provider Name:

Physician / Provider Specialty:

Referral Date:

MonthDayYear

Physician / Provider Address:

Address

Indirizzo Riga 2

City

Zip Code

Physician/Provider Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Physician/Provider Email:

example@example.com

Name:

First NameLast Name

Date of Birth:

MonthDayYear

Patient Address:

Address

Indirizzo Riga 2

City

Post Code

Home/Cell Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Email:

example@example.com

Which treatment do you feel is most appropriate for this patient?

Other

Do you believe this patient may have an active substance use disorder?

Is this or has this patient received therapy in the past?

Patient's Relevant Medical History:

Patient's Previous Psychiatric Medication(s):

Patient's Current Psychiatric Medication(s):

Please select any of the following potential contraindications:

Other Information

1. The patient will be contacted by our office for screening and scheduling. They will receive pre-procedure instructions prior to their initial consultation. If deemed an appropriate candidate for ketamine therapy, Spravato, or TMS, the patient may proceed with the recommended course of treatment.

2. The patient will receive treatments of ketamine, Spravato, or TMS over a three-week period. Ketamine dosing typically begins at approximately 0.5 mg/kg and is adjusted individually based on clinical response, tolerability, and provider assessment.

3. We will monitor the patient’s mood and clinical progress throughout the course of treatment. Following completion of the acute treatment series, we will determine whether ketamine therapy, Spravato, or TMS has been effective in improving symptoms of treatment-resistant depression and other target conditions. For patients who respond favorably, we may recommend maintenance treatments based on clinical need and ongoing assessment. Maintenance infusions are given every 7 to 16 weeks.

Please read the following and sign below:

This patient and I would like to initiate ketamine therapy as an adjunct to the management of the above illness.

I acknowledge that additional information about this therapeutic option is available if we discuss treatment options in more detail.

I will follow up with this patient during and after the TMS + Mind MD treatment course, or refer him/her to a licensed medical professional for follow-up.

Relevant Medical Reports

Referring Physician / Provider Signature

Patient Ketamine & TMS Referral Form

Your Practice Details:

Patient Details:

Treatment Protocol: