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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