Ketamine Provider Referral Form Ketamine Provider Referral FormPatient Name:Date:Patient DOB:Phone:Reason for referral:Current medications and doses:Medical Diagnoses: Psychiatric Diagnoses:If known, please note any positive history of the below by checking the appropriate boxes:Substance use disorder. Please note Substances(s)used:History of treatment with Ketamine:Referring Clinician Name:Address:PhoneFax:EmailIf consult is urgent, please contact our office and send formSubmit Form