Provider Referral Form

Reason for Referral: (Check all that Apply)

Current Treatments:

Checklist Prior to Referral:

Please Submit Completed Form Online (by clicking the button below) or click here to download a copy of this form to fax to Revitalist at 865-674-5089

** Ketamine infusion therapy is one part of your patient's comprehensive treatment. We require patients to maintain continuity with their referring provider following the completion of their ketamine treatments.