Ketamine Referral

Alive Health+Wellness

Ketamine Referral

Patient Name(Required)

First Last

Patient Email(Required)

Patient Phone(Required)

Guardian Name

First Last

Guardian Email

Guardian Phone

Diagnosis(Required)

Major Depression Disorder

Generalized Anxiety Disorder

Post Traumatic Stress Disorder

Seasonal Affective Disorder

Other (please fill out line below)

Diagnosis (other)

Ordering Clinician(Required)

First Last

Ordering Clinician Email(Required)

Ordering Clinician Phone(Required)

Ordering Clinician License Number(Required)

We are are a diverse medical wellness center with treatments for your mental and physical wellbeing. Alive Health + Wellness provides services from boosting inner health to skin rejuvenation methods to enhance your outer aesthetic. The team at Alive Health + Wellness offers an array of services so you look and feel your very best.

Contact Us

Phone

636-821-1168

Address

2634 MO-109, Suite A
Wildwood, MO 63040

Ketamine Referral

Alive Health+Wellness