Confidential Patient Referral Form

If you are a medical professional and you have a patient you would like to refer to the Ketamine Clinic of Hawaii, just fill out the form below and submit. We will respond to you as soon as possible. There is also a link (bottom of page) to a referral form you can download, fill out and print for increased security and confidentiality if you so choose.

Confidential Patient Referral Form

Patients Birthdate

Why are you referring your patient for Ketamine Infusion?

Referrer Contact Information




Download Confidential Patient Referral Form PDF Clicking the link will give you the ability to fill out, print and/or download the referral form.

Contact Us

Contact Us

Ketamine Clinic Hours

Monday 9:00AM – 4:30PM

Tuesday 9:00AM – 4:30PM

Wednesday 9:00AM – 4:30PM

Thursday 9:00AM – 4:30PM

Friday 9:00AM – 4:30PM

Saturday 9:00AM – 1:00PM

Sunday Closed

If your suffering from chronic pain, severe depression, PTSD and your interested in Ketamine infusion treatement, give us a call or email us!

Our Location

Ketamine Clinic of Hawaiic
500 Ala Moana Blvd Unit #4-470
Honolulu, HI 96813
Phone: 808-945-5433