Clinician Ketamine Referral Form

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)

Patient First Name

Patient Last Name

Date of Birth

Address

Contact Phone

Alternate Phone

Indication for Ketamine Check all that apply

Major Depressive Disorder

Bipolar II Disorder

PTSD

Other

Current Medications and Doses

If not taking medications write 'none.'

Prior Medication Trials

Brief Clinical History

Potential Contraindications to Ketamine

Current Psychotic Depression

History of Substance Abuse/Dependence

Severe Personality Disorder

History of Psychosis

Uncontrolled Hypertension

Cerebral Aneurysm

Allergy to Ketamine

Dementia

Current Illicit Substance Abuse

Unstable Medical Disorder

Pregnancy/Breastfeeding

None of the above

Are you Referring this Patient for treatment with:

IM Ketamine

Intranasal Ketamine

Either Formulation

Referring Clinician Name

Date

Phone Number

Fax Number

Your information will be encrypted.

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)

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Clear

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Hide