Mind and Body Infusion Therapies
Provider Referral for Ketamine Infusion TherapyKetamine Infusion Provider: Mind and Body Infusion Therapies, LLCI am currently treating (patient name): _____________________________________________________ For (list conditions & diagnosis)________________________________________________________________________________________________________________________________________________I feel that Ketamine infusion therapy may benefit this patient and am referring him/her for evaluation as an adjunctive treatment for his/her diagnosis. I agree to collaborate with my patient’s Ketamine provider regarding the treatment of my patient.I acknowledge that I may contact my patient’s provider to discuss the treatment protocol and may review more information about this therapeutic option at will continue to follow and direct the care of my patient during and after the completion of the course of therapy and if applicable, will coordinate his/her care with his/her primary care or psychiatric physician. Provider Signature and Date: _____________________________________________________________Printed name: _________________________________________________________________________Phone Number: ___________________________CONFIDENTIAL ................
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