Provider Referral Form for ketamine infusions'

At MKW Institute, our goal is to provide ketamine infusions as adjunct therapy to the patient's current medical treatment plan for depression, anxiety, PTSD, & suicidal ideation.  If you have a patient that you feel may benefit from ketamine therapy, the only step you need to take is to provide a patient referral.  The dose of ketamine to be administered will be determined, regulated and adjusted by the MKW Institute Infusion Protocol. 

Providers please download the attached referral form and return via fax 763-432-5721 or email; Please be sure to include the patient's contact information, email or phone number, and one of our MKW Institute Staff members will contact the referred patient to schedule an appointment.  Please feel free to contact our office with any questions or concerns at 612-394-8717. 

Contact Us

The Minnesota Ketamine & Wellness Institute

9325 Upland Ln N, Suite 370, Maple Grove, MN 55369 612-394-8717

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