Refer a Patient

Name: Chicago IV Solution
Telephone: 844.948.6337
Price range: $

To refer a patient, please fill out the form on this page. All information is confidential. This website operates on a secure server (SSL protected) and has sitelock web security so all information you provide is encrypted and safe. We never share your information with 3rd parties.

You may also contact us via phone Monday – Friday 9:00am – 5:00pm.

Phone: 844-948-6337 | Fax: 844-633-2390

Ketamine Centers of Chicago 712 N. Dearborn St., Chicago, IL 60654

Ketamine Centers of KC 6500 W. 143rd St., Overland Park, KS 66223

See Additional Contact Information Below

Date
MM slash DD slash YYYY
Name of Referring Provider or Physician*
Referring Provider or Physician's Speciality*
Referring Provider or Physician's Email*
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Referring Provider or Physician's Phone Number
Patient's Name*
Patient's Email*
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Patient's Phone
Diagnosis*
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Contact Us

844.948.6337

info@chicagoivsolution.com