CONFIRMATION OF PATIENT CARE FORM:

This form simply acknowledges that you and the patient you name have an ongoing relationship and that he/she is under your care.  Completion of this form does NOT imply recommendation or approval of ketamine infusion therapy.  If you have already completed the Patient Referral Form, you do not need to complete this form.

Please either fill out the form below or print the form here and fax to 609-414-7378.