Specialty Medication Clinic -

External Referral

 
 

 

Patient Information

 
 
 
 
 
 
Phone
 
 
 
 
 
Phone
 
 
 
 
 

 

Patient Demographics

 
 
 
 

 

Presenting Problem(s)

 
 
 
 
  • Aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial, and peripheral arterial vessels) or arteriovenous malformation
  • History of intracerebral hemorrhage
  • Hypersensitivity to Esketamine, ketamine, or any of the excipients.


I have discussed this with my patient and they attest that they do not have any of the above stated conditions.

 
 
 
 
 

 

NOTE:

To fully process this referral, please upload or fax a copy of:


1.) the most recent medical note

2.) medication history and

3.) the front and back of the individual's insurance card.


Fax: 802-258-3788

 
 

If these requested documents are not received, the referral cannot be fully processed and will result in a delay. If you are faxing these documents, please indicate so. Thank you.

Drop your files here
 

 

Referring Provider Information

 
 
 
 
Phone