Provider Referral

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 info@mkw-institute.com.

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.

Complete the Provider Referral Form Below

NOTE: Only prescribing providers can refer patients (i.e. providers that have the ability to prescribe patients medication).

I Am Currently Treating (Patient Name) :(Required)

Date of Birth:(Required)

Patient Contact Phone Number :(Required)

Diagnosis : Diagnostic Codes Must Be Listed With Severity Prior To Submission For Referral To Be Approved

1. ICD-10 Code(Required)

1. Diagnosis(Required)

2. ICD-10 Code

2. Diagnosis

3. ICD-10 Code

3. Diagnosis

4. ICD-10 Code

4. Diagnosis

Additional Diagnosis/Conditions/Comments :

For Patients Transferring From Another Facility That Currently Receive Ketamine Therapy, List The Following Information :

Last Ketamine Dose (mg/kg) :

Total Dose Administered (mg) :

Over

Minutes.

Any Additional Medications & Dose Administered Prior To, During, Or Post Infusion :

I Believe That Ketamine Infusion Treatments May Benefit My Patient And Am Referring Them For Ketamine Infusion Therapy To The Minnesota Ketamine & Wellness Institute, Maple Grave, Minnesota. I Acknowledge And Agree To Collaborate With MKW-Institute Regarding The Treatment Of My Patient.

I Acknowledge That I Can Contact MKW-Institute To Further Discuss The Treatment Protocol And May Further Review Information About This Therapeutic Treatment Option. I Will Continue To Follow And Direct The Care Of My Patient Throughout This Course Of Therapy Or Collaborate Their Care With A Primary Provider Or Mental Health Provider.

Signature(Required)

Date(Required)

Prescribing Provider And Clinic Name(Required)

Phone Number(Required)

Prescribing Provider Credentials (MD, DO, PMHNP, CNS, FNP, PA-C)(Required)

Provider Referral