Referrals For doctors’ use only Patient's Full Name Date of Birth Sex Male Female Other Email Address Telephone Number Diagnosis (please tick all that apply) Treatment Resistant Depression Anxiety PTSD Other (please specify below) Current Medications Brief History Referring Clinician Full Name GMC Number Telephone Number Email Adress Specialty This patient, with my consent, wishes to initiate Ketamine Infusions at Pasithea Clinic. On clinical examination of this patient, I was able to certify that to the best of my knowledge, there are no medical contraindications for undergoing Ketamine infusion therapy. I agree to be contacted regarding this patient if required and I have clearly indicated all special instructions (if required) above. Submit
