I am currently treating the following patient:
Patient Information
Symptoms
Because I am concerned about the severity of this patient’s symptoms and/or have seen suboptimal response to multiple treatments, including:
This patient and I would like to initiate ketamine infusion therapy as an adjunct to the management of this illness.
I acknowledge that I may review information about this therapeutic option at www.ketaminehealthtx.com, or contact the Ketamine Health & Wellness Center at (972) 212-4341 to discuss the treatment protocol.
I will follow up with this patient during and after the completion of the treatment course at the Ketamine Health & Wellness Center.
Referring Physician Information
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