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.
Ketamine Wellness Centers
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.
603 E Diehl Rd, Suite #139 Naperville, IL 60563
Dallas-Fort Worth, Texas
6144 Precinct Line Road, Suite 100 Hurst, TX 76054
7261 S Broadway, Suite 10-L Littleton, CO 80122
12807 Haynes Rd. Building A, Unit 1 Houston, TX 77066
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
2451 E. Baseline Rd, Suite 300 Gilbert, AZ 85234
3724 N 3rd. St. Suite 201 Phoenix, AZ 85012
1895 Plumas St. #6 Reno, NV 89509
Salt Lake City, Utah
6087 S. Redwood Road STE. B Taylorsville, UT
34709 9th Ave S. Suite-B 200 Federal Way, WA 98003
3130 N Swan Rd. Tucson, AZ 85712