Referrals Lorem ipsum dolor sit amet, consectetur adipiscing elit. Are You Eligible? Are You Eligible? For doctors’ use only Sex Male Female Other Diagnosis (please tick all that apply) Treatment Resistant Depression Anxiety PTSD Other (please specify below) This patient, with my consent, wishes to initiate Ketamine Infusions at Pasithea Clinic. On clinical examination of this patient, I was able to certify that to the best of my knowledge, there are no medical contraindications for undergoing Ketamine infusion therapy. I agree to be contacted regarding this patient if required and I have clearly indicated all special instructions (if required) above. Submit
