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(469) 529-7579
Mon - Sunday By Appointment
1626 W Hwy 287 Bus #101 Waxahachie, TX 75165
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Menu
Home
About Us
Ketamine Treatment
Ketamine In The News
Financing
FAQs
Condition
Anxiety
Bipolar Disorder
Chronic Pain
Back Pain
Cancer Pain
CRPS
Fibromyalgia
Migraines
Neuropathic Pain
Depression
OCD
PTSD
Postpartum Depression
Substance Abuse
Suicidal Ideation
IV Therapy
Get Up And Go
Immunity
Quench
Reboot
Recovery & Performance
Resources
Our Blog
Osmind
Research Articles
Referral Form
Get Started
Referral Form
ELEVATE INFUSION THERAPY
Provider Referral for Ketamine Infusion Therapy
Ketamine Infusion Provider:
I am currently treating (patient name)
(Required)
For (list conditions & diagnosis)
I feel that Ketamine infusion therapy may benefit this patient and am referring him/her for evaluation as an adjunctive treatment for his/her diagnosis. I agree to collaborate with my patient’s Ketamine provider regarding the treatment of my patient.
I acknowledge that I may contact my patient’s provider to discuss the treatment protocol and may review more information about this therapeutic option at
https://elevateinfusiontherapy.com
I will continue to follow and direct the care of my patient during and after the completion of the course of therapy and if applicable, will coordinate his/her care with his/her primary care or psychiatric physician.
Referring Provider Name
Provider's Phone Number
Date
Call Us
Consultation