Provider Referral

By submitting and signing the form below, you are agreeing to the following: I believe that ketamine infusion treatments may benefit my patient and am referring them for ketamine infusion therapy to Minnetonka Wellness Center LLC and their providers. I acknowledge and agree to collaborate with Minnetonka Wellness Center and their providers regarding the treatment of my patient. I acknowledge that I can contact Minnetonka Wellness Center 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.

Referring Provider Name (with credentials)*

Email*

Phone*

I am currently treating (Patient Name)*

Patient Date of Birth*

Patient Contact Phone Number*

ICD-10 Code*

Diagnosis*

Signature of Provider*

Date of signature*