Urgent Care Plus Ketamine Therapy Referral Form

  • Urgent Care Plus Ketamine Therapy Referral Form

  • Low dose Ketamine is meant primarily for the treatment of refractory depression, depression and pain related to palliative care, and chronic refractory neuropathic pain.

    Contraindications include: Age < 18 years, unstable medical conditions including hypertension, angina, severe respiratory illness, glaucoma, schizophrenia, psychosis, or anything that would be considered a risk for outpatient procedures. Chronic use of high doses of benzodiazepines may also impact the response to ketamine.

  • Patient Demographic Information

  • Patient Date of Birth
     - -
  • Format: (000) 000-0000.

  • Referring Clinician Demographic Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Patient History

  • Reason for ketamine infusion:
  • Does the patient have a history of substance abuse/treatment?
  • Does the patient have a history of psychiatric admission, suicide attempts or psychotic episodes?
  • Does the patient have the capacity to make their own medical decisions?
  • Should be Empty: