Refer a Patient

Referring Office Contact Information

Referring Physician

Your Name

Phone Number

Email Address

Fax Number (Optional)

If you would like a confirmation of your patient's appointment, please provide your fax number.

Patient Information

Patient Name

Patient Phone Number

Patient Alternative Phone Number

Patient Email Address

Patient Date of Birth

Symptoms & Diagnosis

Reason for Appointment Request

Ketamine for Mental Health

Ketamine for Pain

Medical Cannabis Card

Requested Time to Be Seen

1-2 Days

3-5 Days

Math question

7 + 12 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.