Provider Referral Form

Spravato indications:

Treatment resistant depression (TRD) defined as having tried at least 2 antidepressants from different drug classes titrated to the highest tolerated dose during the current depressive episode.
Major depressive disorder with suicidal ideation.

Spravato exclusion criteria:

Allergy/sensitivity to ketamine or esketamine
History of aneurysm
Uncontrolled high blood pressure
Severe, untreated sleep apnea
Pregnancy or potential pregnancy/breast feeding
History of or current psychosis/schizophrenia

To complete this referral please fax visit notes and patient insurance information to 828-412-0225.

Feel free to reach out to our medical team to discuss specific referral cases or to have one of our medical team members speak to your practice about the Pearl's programs. The Pearl Institute 828-378-1527 or info@pearlpsychedelicinstitute.org

Please note that we do not currently accept patients for general psychiatric medication management.

Select Service

Spravato

Ketamine

Date

Patient Info

First Name

Last Name

Date of Birth

Month

Day

Year

Phone Number

Patient Address

Country/Region

Address

City

Zip / Postal code

Referring Physician Info

Referring Physician

Reffering Physician Phone Number

Patient Medical Info

Current Medications and Doses

Allergies

Reason For Referral

To complete this referral please fax visit notes and patient insurance information to 828-412-0225.