REFERRALS | My Site

PROVIDER REFERRALS

At Show Me Care Infusion Therapy, our goal is to provide ketamine infusions as adjunct therapy to the patient’s current medical treatment plan for mood disorders such as depression, anxiety, PTSD, postpartum depression, OCD, bipolar depression, substance use disorder, and suicidal ideation: and chronic pain syndromes such as complex regional pain syndrome, fibromyalgia, neuropathy and chronic migraines.

If you have a patient that you feel may benefit from ketamine therapy, the only step you need to take is to provide a patient referral. The dose of ketamine to be administered will be determined, regulated and adjusted by the Show Me Care Infusion Therapy Infusion Protocol.

Providers, we’d love for you to fill out the online form below to tell us more about the patient. Please be sure to include the patient’s contact information (email or phone number), and one of our staff members will contact the referred patient to schedule an appointment. Feel free to contact our office with any questions or concerns at 314-447-8847

I am currently treating (Patient Name)

Patient Birthday

Patient Phone

Add your text

ICD-10 Code 1

Diagnosis 1

ICD-10 Code 2

Diagnosis 2

ICD-10 Code 3

Diagnosis 3

ICD-10 Code 4

Diagnosis 4

Additional Diagnosis/Conditions/Comments

For patients transferring from another facility that currently receive Ketamine Therapy, list the following information:

Last Ketamine Dose (mg/kg)

Total Dose Administered (mg)

Over

Minutes

Any additional medications & dose administered prior to, during, or post infusion:

I believe that Ketamine Infusion Treatments may benefit my patient and am referring them for Ketamine Infusion Therapy to the SMC Infusion Therapy. I acknowledge and agree to collaborate with SMC Infusion Therapy regarding the treatment of my patient.

I acknowledge that I can contact SMC Infusion Therapy to further discuss the treatment protocol and may further review information about this therapeutic treatment option. I will continue to follow and direct the care of my patient throughout this course of therapy or collaborate their care with a primary provider or mental health provider.

Today's Date

Prescribing provider and clinic name

Phone Number

Prescribing provider credentials (MD, DO, PMHNP, CNS, FNP, PA-C)

Complete the provider referral form below.