Patient Referral Form

At Luvita, our providers strive for collaborative, patient-centered care. Therefore, we strive to complement patient and practitioner goals for a synergistic, customized care plan. We thank you for your time and look forward to working with you.

Please fill out the secure form below to refer your patient for ketamine therapy or integrative psychiatry. All submissions are encrypted and HIPAA compliant, and we will never share your or your patient’s information with third parties. You may instead download a pdf version HERE and fax it to us if you prefer.

This form is exclusively for medical providers or mental health professionals seeking a referral for their patients.

Patient Referral Form

Referring Provider(Required)
Practice Address
How would you like to recieve updates on your patient? *(Required)


Patient Information

Name(Required)
MM slash DD slash YYYY
Gender
Address