Braxia Health Self Referral Form

Completing this form does not guarantee access to treatment. This form authorizes Braxia Health to contact your community physician on your behalf for a referral. When your community physician completes the referral it will be assessed for eligibility. If eligible, you will be booked in with a member of our physician team for a more in depth referral whereby it will be decided if you are a suitable candidate for ketamine treatment.


    YOUR INFORMATION

    Your Name (required)

    Your Phone Number (required)

    Your Email Address (required)

    TREATMENT TYPE REQUEST (required)

    IV KetamineSublingual Ketamine


    YOUR PHYSICIAN’S INFORMATION

    Your Physician's Name (required)

    Your Physician's Address (required)

    Your Physician's Phone Number (required)

    Your Physician's Fax Number

    By checking this box I authorize Braxia Health to send me information emails.

    By checking this box I authorize Braxia Health to contact my physician regarding this program on my behalf.

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