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).
  • MM slash DD slash YYYY
  • PATIENT INFORMATION

  • MM slash DD slash YYYY
  • 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

    • NATURE OF THIS 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