This form is for clients currently in the Safe Haven Health Ketamine Treatment Program. If you are not a current client, please schedule an initial ketamine appointment here.

Please complete this form for your refill request to be processed appropriately. Please keep in mind that there are NO early refills for Ketamine, NO exception. If you are requesting a dose change, please contact your provider before filling out this form. Your request needs to be for your current prescribed dose and dosing schedule.

Please allow two business days for your request to be processed. If there is an overdue balance, your refill won’t be processed until the balance is paid. If you have any questions or concerns, please contact us via the patient portal or at 720-637-5809.