THIS FORM IS TO BE COMPLETED BY THE PATIENT'S REFERRING HEALTHCARE PROVIDER
DO NOT COMPLETE THIS FORM IF YOU ARE THE PATIENT
Dear Healthcare Provider,
Thank you for considering referring your patient to Emerge Ketamine for consideration of ketamine intravenous therapy (KIT) or intranasal Esketamine (Spravato). To refer your patient, please complete this HIPAA-compliant questionnaire.
We strive to provide safe, effective and collaborative care for all our patients undergoing ketamine care and therefore request the referring provider’s contact information including a HIPAA secure email so that we can work collaboratively and update you with patient progress. Your contact information will only be used by Emerge Ketamine and will not be shared, sold or otherwise distributed.
Sincerely,
Dr. Joseph Benedict
Dr. Liam Mahoney
www.EmergeKetamine.com
[email protected]
100 Tradecenter Drive G-700
Woburn, MA 01801
P: 781-776-1944 F: 877-492-2893
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