Provider Referral Form

Thank you for referring your 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.

Today's Date*
MM slash DD slash YYYY
PATIENT INFORMATION
Name*
First Last
Date of Birth*
Month
Day
Year
Phone*
Email
Which KWC clinic location does the patient want to receive treatment at?
How would you like to submit the patient's medical records?*
- Upload to this form
- Fax to our secure line: (844) 538-9355
Patient Medical Records*
Drop files here or

Max. file size: 50 MB.
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

Provider Referral Form

PATIENT INFORMATION

REFERRING PHYSICIAN INFORMATION

NATURE OF THIS REFERRAL

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