Request for ketamine therapy to be performed by Dr. Leverone
I am the physician treating patient named ______________________________ for chronic pain. The patient and I feel that the pain syndrome could benefit from treatment with ketamine infusion therapy, and am therefore referring this patient for ketamine infusion treatments at your center. I will help provide all necessary pre-procedure documentation of the pain syndrome including request for ketamine, and lab work which is required by your center. I am also acknowledging that I will continue to follow this patient after completion of the treatment.
I have discussed ketamine therapy with my patient and we have determined that we are requesting ketamine infusion for ___ days.
Patient name: _________________________________
Address: _________________________________
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_________________________________
Phone: _________________________________
Fax: _________________________________
Email: _________________________________
Physician name: _________________________________
Address: _________________________________
_________________________________
_________________________________
Office phone: _________________________________
Office fax: _________________________________
Cell phone/pager _________________________________
Email: _________________________________
Physician Signature ________________________________
Fax completed referral form to: Los Angeles 310-208-0970
Watsonville 831-763-9799
