Patient Referral Form

Ketamine Treatment Referral Form

Please complete Patient Referral Form below.

Thank you for allowing us to assist in the care of your patient.

First Name

Last Name

Date of Birth

Phone Number

Primary Diagnosis

HAS THE PATIENT BEEN PRESCRIBED MORE THAN ONE MEDICATION OR TREATMENT FOR THEIR DIAGNOSIS?

Yes No

HAS THE PATIENT REPORTED MEDICATIONS OR TREATMENTS PRESCRIBED HAVE BEEN INEFFECTIVE IN TREATING HIS/HER SYMPTOMS?

Yes No

CURRENT MEDICATIONS (DEPRESSION, ANXIETY, PAIN, ONLY)

Provider Name

Provider Speciality

Provider's Phone

Provider's Email

Reason for Refferal

WOULD YOU LIKE Gateway Clinics TO CONTACT YOU WITH PATIENT UPDATES?