SPRAVATO® Recommendation Form

Thank you for taking the time to support your patients continued care for their treatment-resistant depression. While we don’t require any additional info, as we will be careful in conducting a thorough eval on patients upon referral, if you feel that you have any additional information that might be instrumental in ensuring an optimal continuity of care, please feel free to enter it below.

SPRAVATO® is contraindicated in patients with:

Aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial and peripheral arterial vessels) or arteriovenous malformation.
History of intracerebral hemorrhage.
Hypersensitivity to esketamine, ketamine, or any of the excipients.

For more information about SPRAVATO®, see our page on Depression Treatment.

Patient's Name

First Name

Last Name

Patient's Email

Patient's Phone

(###)

###

####

Additional Information (optional)

How can we best serve you in this process?

Would you like to coordinate with us for the patient’s continued care while we administer SPRAVATO® treatment?

Or would you like us to fully assume care for the patient's psychiatric needs?

If you would like us to stay in contact with you as we administer treatments, what contact information is best for you?

What is your role in referring this patient?

Primary Care Physician

Psychiatrist

Counselor

Family member

Friend or caregiver

Greenbrook TMS NeuroHealth center in North Carolina

Other

How did you hear about us?

SPRAVATO® Recommendation Form

Location

Hours

Contact

frontdesk@excelpsychiatric.com

call or text: 704-457-9292