Provider Referral for Ketamine IV Therapy

Provider Referral

At Illuminate, we are committed to collaborating with providers to ensure patients receive the highest quality of care. Ketamine infusions, in conjunction with ongoing therapy and medication management, has proven to be a successful and sustainable treatment option for those struggling to find relief.

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Provider First Name

Provider Last Name

Provider Phone

Provider Email

Provider Fax

Name of Practice

Patient First Name

Patient Last Name

Patient Phone*

Patient Email*

Patient DOB

Patient's Condition and Diagnosis

Reason for Referral

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Provider Referral

Provider Referral

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