PROVIDER REFERRALS

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This patient and I would like to initiate ketamine infusion therapy as an adjunct to the management of the above illness. I acknowledge that I may review information about this therapeutic option at www.divinewellnessclinic.com and that I may contact the Divine Wellness Clinic to discuss the treatment. I will follow up with this patient during and after the completion of the treatment course at Divine Wellness Clinic or refer him or her to a licensed medical professional for follow-up.


Patient Referral Form

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Consultation