IMG_1896

Patient Referral

Thank you for allowing us to assist in the care of your patient.

Dear Colleague,

Thank for your trust in NMKW. We offer sub-anesthetic ketamine infusions for the relief of Treatment Resistant Depression, PTSD, chronic intractable migraines, and complex regional pain syndrome as well as some other chronic pain syndromes. This is done in a safe, monitored, calm, and comfortable setting provided by a board-certified anesthesiologist.

If you have any questions regarding your patient’s candidacy for this treatment, please do not hesitate to contact us. Otherwise please complete the patient referral form. With your patients permission we will request medical records pertinent to the referring diagnosis.

We promise to be in close contact with you regarding their treatment response and outcome.

Drs Rivard and Griffith

Phone:  989-350-9155

FAX:  989-448-8004

or mail to:

Northern Michigan Ketamine and Wellness, PLC

289 West Commerce Blvd#1806

Gaylord, MI 49734

 

400dpiLogoCropped

 

Please complete this Patient Referral Form.

Thank you for allowing us to assist in the care of your patient.