Refer a Patient Patients Name* Date of Birth* Phone*Email* Primary Psychiatric Diagnosis:* Secondary Psychiatric Diagnoses:* Mental Health Provider's Name** Provider's Phone:*Provider's Address:* Provider's Specialty:* Provider's Fax:* Provider's Email:* Would you like us to call you prior to starting ketamine treatments?* Yes No Comments:HiddenGravity Forms Hiddenutm_source CommentsThis field is for validation purposes and should be left unchanged. I can be reached to discuss your patient or Ketamine therapy by phone at (414) 310-7178. I look forward to working with you in the care of your patient. Kevin J. Kane, MD