This form must be completed by a treating clinician (Physician, NP, Psychologist)
Please correct the errors described below.
Thank you for referring your patient for Ketamine treatment at ANSR Clinic
If you have any questions about Ketamine treatment, please do not hesitate to call us or send us an email at info@ansrclinic.com. We are located at 1171 Bedford Highway, Bedford, Nova Scotia.
902-466-2677
902-455-2677 (Fax)
If not taking medications write 'none.'
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Thank you for referring your patient for Ketamine treatment at ANSR Clinic
If you have any questions about Ketamine treatment, please do not hesitate to call us or send us an email at info@ansrclinic.com. We are located at 1171 Bedford Highway, Bedford, Nova Scotia.
902-466-2677
902-455-2677 (Fax)
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