Provider Referral Form for Ketamine Infusions
At Minnesota Ketamine & Wellness Institute, our goal is to provide ketamine infusions as adjunct therapy to the patient’s current medical treatment plan for depression, anxiety, PTSD, postpartum depression, OCD, bipolar depression, substance use disorder, and suicidal ideation.
If you have a patient that you feel may benefit from ketamine therapy, the only step you need to take is to provide a patient referral. The dose of ketamine to be administered will be determined, regulated and adjusted by the MKW Institute Infusion Protocol.
Providers, we’d love for you to fill out the online form below to tell us more about the patient. You can also download the referral form by clicking here and return it via fax at 763-432-5721 or email at firstname.lastname@example.org.
Please be sure to include the patient’s contact information (email or phone number), and one of our MKW Institute Staff members will contact the referred patient to schedule an appointment. Feel free to contact our office with any questions or concerns at 612-502-2800.