Ketamine Referral

Please ensure all categories are completed prior to submission.

This referral form is for assessment and if patient is suitable, the administration of Ketamine Treatment at QueenslandTMS.

Novel Treatment Program Referral Form

Patient Information

Medical Diagnosis

Alcohol or drug misuse
Cardiovascular condition
Chronic pain
Head injury/neurological disorder
Hepatic disease
Kidney problems
Past Ketamine use
Urinary or bladder condition

GP Information

Referring Doctor Declaration

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.

Request more info

Contact Us