Forms 2018-11-19T23:01:10+00:00

FOR PATIENTS

Please complete a “Patient Health Assessment Form” and fax or email the form back to our clinic. If you do not have access to a fax machine or a scanner, please call us to complete the Patient Health Assessment Form by phone.

FOR REFERRING PROVIDERS

To refer a patient, providers need to complete our “Physician Referral Form” and fax or email the form back to our clinic.

All assessments and referrals are reviewed by our physicians. Our clinical coordinator will contact you prior to scheduling your appointment.

CONNECT WITH US

Email: info@ketamineoc.com
Phone: (949) 499-7500 24 hours/day support
Fax: (949) 499-7582

CONTACT US

CONTACT INFORMATION

MISSION HOSPITAL – LAGUNA BEACH

ADDRESS:
31852 COAST HIGHWAY
PHYSICIAN CENTER WEST, SUITE 400
LAGUNA BEACH, CA 92651
PHONE: (949) 499.7500 (24 HOUR/DAY SUPPORT)
FAX: (949) 499.7582
EMAIL: INFO@KETAMINEOC.COM

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