Refer a Patient for Ketamine Treatment

Referrals are not required at Áureo as our providers will always conduct a thorough medical evaluation before providing any ketamine treatment services.

However, if you’d like to refer a patient to us for these services, please fill out the following form and we will reach out to them within 1-2 business days.

Patient's Name

First Name

Last Name

Preferred Pronoun(s):

Best way to contact patient (email or phone)

Provider's Name

First Name

Last Name

Clinic Name

Provider's Email

Provider's Phone

(###)

###

####

Provider's Fax Number

(###)

###

####

Checkbox

IV Ketamine Treatment

IM (Intramuscular Injections) Ketamine Treatment

Oral Ketamine Treatment

Ketamine Medical Evaluation Only

Ketamine Integration Services

Not sure, please discuss all options with the patient and determine best treatment course

Reason for Referral

Checkbox

Is this an Urgent Referral?

Urgent

Standard

Notes or anything else we should know about this referral?