Let’s Work Together

Close-up of a person's hands typing on a laptop keyboard with a stethoscope lying on the wooden desk in the foreground.

Let’s Work Together

At the time of referral, the patient may visit our website to schedule an appointment and complete all necessary forms. This can be done by visiting our website and clicking “Book an appointment”. They may also contact our office at (509) 426-4726.

If you feel your patient would benefit from treatment, please fill out the form below.

Alternatively, you may email info@prismketaminetherapies.com with
all pertinent patient and referral information. This will waive the patient’s
need to schedule an initial consultation and the patient may begin ketamine
treatment. We will still complete an intake process to ensure that there are
no contraindications to treatment.

Please note: We do call and verify all referrals.

Provider Name

First Name

Last Name

Email

Phone

(###)

###

####

How did you hear about us?

Patient Information

First Name

Last Name

Patients DOB

Phone

(###)

###

####

Email

Diagnosis/Reason for Treatment:

Additional Information

Please include any additional Information you feel would be helpful,