Clinician Ketamine Referral Form

If you have any questions about Ketamine treatment, please do not hesitate to call us or send us an email at info@ansrclinic.com.

Client Information

Patient First Name

Patient Last Name

Date of Birth

Email Address

Contact Phone

Alternate Phone

Address

Indication for Ketamine Check all that apply

Major Depressive Disorder

Bipolar II Disorder

PTSD

Other

Current Medications and Doses

Please indicate 'None' if not taking any medications currently

Prior Medication Trials/ECT/rTMS/Other

Please indicate 'none' if there are no previous medication trials

Brief Clinical History

Please include any known allergies

Please describe any of the conditions checked off above

Ketamine Treatment Referring For:

IM Ketamine

Intranasal Ketamine (IN)

Intravenous Ketamine (IV)

Patients's Preferred Clinic for Treatment:

Bedford, NS

Modalities available IM, IN, IV

Wolfville, NS

Modalities available IN, IM, IV

Sydney, NS

Modalities available IN

Fredericton, NB

Modalities available IN, IM

St. John's, NL

Modalities available IN, IM, IV

Calgary, AB

Modalities available IN

Edmonton, AB

Modalities available IN

Referring Clinician Name

Date

Phone Number

Fax Number

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