Spravato ® Provider Referral

Schedule a free consultation today and start your journey to a healthier, happier life.

Schedule Consultation

To be completed by the provider

Please contact us using the details below if you would like to speak to, or coordinate care with one of our staff

PATIENT INFORMATION

First Name

Last Name

Date of Birth

Address

Zip

Phone Number

Email

Can a voicemail be left at this number for an appointment?
Yes

No

Primary Insurance

Policy

Group

Policy Holder Name

Card/BIN

Caregivers Name

Caregivers Phone Number

Please see full prescribing information, Including BOXED WARNINGS, and Medication Guide for Spravato ®
YOUR MEDICAL HISTORY

Your Diagnosis

Medical / Treatment History

Medications History

Additional medical reports and supporting documents are included with this form? Please upload below
Yes

No

Please see full prescribing information, Including BOXED WARNINGS, and Medication Guide for Spravato ®
REFERRING HEALTHCARE PROVIDER INFORMATION

Name

Phone Number

Practice

Email

Fax Number

Please notify me with updates regarding my patient through

Please see full prescribing information, Including BOXED WARNINGS, and Medication Guide for Spravato ®

Palmier TMS® is a safe, comfortable place where you are always heard.

Schedule a free consultation today and start your journey to a healthier, happier life.

Schedule free consultation