Provider Referral Form

Thank you for referring a patient to Ketamine Wellness Centers. All records uploaded via the form below are kept confidential. In addition to completing this form, you may fax the patient’s medical records to our secure line: 844-538-9355 (844-KET-WELL).

If you are looking for the Medical Records Release and Request form, you can find it here.

Provider Referral Form

Fill out and submit this form if you are a medical provider who is referring your patient to Ketamine Wellness Centers. After completing the online referral form, please fax the patient's medical records to our secure line.Fax Number: 844-538-9355 (844-KET-WELL).

Date*
MM slash DD slash YYYY
PATIENT INFORMATION
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Phone*
Email
Which KWC clinic location does the patient want to receive treatment at?
Any medical records to include?
Drop files here or

Max. file size: 50 MB.
Alternatively, you may fax the patient’s medical records to our secure line: 844-538-9355 (844-KET-WELL)
REFERRING PHYSICIAN INFORMATION
Name*
First Last
Name of Medical Practice/Office*
Medical Focus/Specialty*
Medical Practice/Office Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone*
Email
NATURE OF THIS REFERRAL
Urgency of the referral?*
- Routine
- Urgent
- Emergency
Reason for Referral

Ketamine Wellness Centers

PHONE:
855-KET-WELL (1-855-538-9355)

FAX:
844-KET-WELL (1-844-538-9355)

EMAIL:
info@ketaminewellnesscenters.com

Ketamine Wellness Center’s mission is to provide personalized, compassionate, high-quality care for people suffering from afflictions where Ketamine infusions have proven a successful treatment option (Depression, Chronic Pain, PTSD, OCD, Suicidality) while actively researching Ketamine’s efficacy to treat additional conditions. There is hope. There is help.

CLINIC LOCATIONS:

Chicago, Illinois
603 E Diehl Rd, Suite #139 Naperville, IL 60563

Dallas-Fort Worth, Texas
6144 Precinct Line Road, Suite 100 Hurst, TX 76054

Denver, Colorado
7261 S Broadway, Suite 10-L Littleton, CO 80122

Houston, Texas
12807 Haynes Rd. Building A, Unit 1 Houston, TX 77066

Jacksonville, Florida
3753-2 Cardinal Point Drive Jacksonville, FL 32257

Las Vegas, Nevada
7375 S. Pecos Rd. Suite 102 Las Vegas, NV 89120

Minneapolis-St Paul, Minnesota
11995 County Road 11, Suite 220 Burnsville, MN 55337

Mesa-Gilbert, Arizona
2451 E. Baseline Rd, Suite 300 Gilbert, AZ 85234

Phoenix, Arizona
3724 N 3rd. St. Suite 201 Phoenix, AZ 85012

Reno, Nevada
1895 Plumas St. #6 Reno, NV 89509

Salt Lake City, Utah
6087 S. Redwood Road STE. B Taylorsville, UT

Seattle, Washington
34709 9th Ave S. Suite-B 200 Federal Way, WA 98003

Tucson, Arizona
3130 N Swan Rd. Tucson, AZ 85712

Provider Referral Form

Provider Referral Form

PATIENT INFORMATION

REFERRING PHYSICIAN INFORMATION

NATURE OF THIS REFERRAL

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