Medical Records Release & Request

This form authorizes your health service provider to submit your medical record (or specific portions of it) to Ketamine Wellness Centers.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • I hereby authorize my health service provider:

  • Date Format: MM slash DD slash YYYY

  • Ketamine Wellness Centers

    Corporate Headquarters: 113 W. Hoover Ave, Ste. 101. Mesa, AZ 85210

    Phone: 855-KET-WELL (855-538-9355)

    Fax: 844-KET-WELL (844-538-9355)

    Our Clinics:

    Mesa-Phoenix: 2152 S. Vineyard Plaza, Suite 131 Mesa, AZ 85210

    Tucson: 3130 N Swan Rd. Tucson, AZ 85712

    Littleton-Denver: 7261 S Broadway, Suite 10-L Littleton, CO 80122

    Bursnville-Minneapolis: 11995 County Road 11, Suite 220 Burnsville, MN 55337

    Hurst-Dallas: 6144 Precinct Line Road, Suite 100 Hurst, TX 76054

    Federal Way-Seattle: 34709 9th Ave S. Suite-B 200 Federal Way, WA 98003