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 download a PDF version and fax it to us if you prefer by clicking here.

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

Patient Referral Form

Specialty(Required)

Referring Provider(Required)

First Last

Name of Practice *(Required)

Practice Address

Street Address Address Line 2 City State ZIP Code

Phone

FAX

How would you like to recieve updates on your patient? *(Required)

Phone

Fax

You do not need to contact me with patient updates.

Patient Information

Name(Required)

First Last

Date of Birth(Required)

Gender

Male

Female

Phone(Required)

Address

Street Address Address Line 2 City State ZIP Code

Diagnosis(Required)

Reason for Referral(Required)

Patient Referral Form

Patient Referral Form

Patient Information

CONTACT US

Hours of operation

AFFILIATES