Ketamine Therapy
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Physician Referral Form

Request for ketamine therapy to be performed by Dr. Leverone

I am the physician treating patient named ______________________________ for chronic pain. The patient and I feel that the pain syndrome could benefit from treatment with ketamine infusion therapy, and am therefore referring this patient for ketamine infusion treatments at your center. I will help provide all necessary pre-procedure documentation of the pain syndrome including request for ketamine, and lab work which is required by your center. I am also acknowledging that I will continue to follow this patient after completion of the treatment.
I have discussed ketamine therapy with my patient and we have determined that we are requesting ketamine infusion for ___ days.

Patient name:       _________________________________
Address:               _________________________________
Phone:                  _________________________________
Fax:                      _________________________________
Email:                   _________________________________

Physician name:    _________________________________
Address:               _________________________________
Office phone:        _________________________________
Office fax:             _________________________________
Cell phone/pager _________________________________
Email:                   _________________________________

Physician Signature  ________________________________

Fax completed referral form to: 831-763-9799

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