Ketamine Referral

Patient Information

Patient Name

Address

Date Of Birth

Phone Number

Medicare Number

DVA / Workcover Number

Medical Diagnosis

Alcohol or drug misuse

Yes

No

Concussion

Yes

No

Cardiovascular condition

Yes

No

Chronic pain

Yes

No

Glaucoma

Yes

No

Hallucinations/dissociation

Yes

No

Head injury/neurological disorder

Yes

No

Hepatic disease

Yes

No

Hypertension

Yes

No

Kidney problems

Yes

No

Past Ketamine use

Yes

No

Urinary or bladder condition

Yes

No

GP Information

Referring Doctor

Provider Number

Practice name & address

Phone

Email

Date

Referring Doctor Declaration

I am referring this patient as their usual treating Psychiatrist or GP who will be providing their ongoing management and care.

QueenslandTMS novel treatment program is medically supervised, but all patients must have their own Psychiatrist or GP who continues to provide primary care during the course of novel treatment.

Please ensure all categories are completed prior to submission.

Patient Information

Medical Diagnosis

GP Information

Request more info

Contact us

Cairns Practice

Mareeba Practice

Innisfail Practice