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).Ketamine Wellness Centers
PHONE:
855-KET-WELL (1-855-538-9355)
FAX:
844-KET-WELL (1-844-538-9355)
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
