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Relax the mind, awaken the spirit
(920) 510-9381
721 Cardinal Lane, Suite 105 Green Bay, WI 54313
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Home
About
Meet The Team
Our Blog
Pay with Cherry
Aesthetics
Botox /Xeomin / Dysport
Dermal Fillers
VI Peel
Vampire Facelift
Vampire Facial
IV Vitamins
IV Hydration/Nutrition
Signature Cocktails
Specialty Infusions
NAD+ Therapy
Injections/Add-Ons
IV Infusion Pricing
Body Wellness
Weight Loss
Emsculpt NEO
Emsculpt NEO
Emsella
Ketamine
Treatments
Depression
Anxiety
PTSD
OCD
Bipolar Disorder
Chronic Pain
Fibromyalgia
Migraine Headaches
Neuropathic Pain
CRPS
RLS
Financing
Provider Referral
Science & Research
Ketamine Experience
Ketamine FAQs
Free Consultation
Provider Infusion Referral
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»
Provider Infusion Referral
Provider Referral
First Name
Last Name
Phone
Email
Date Of Birth
MM slash DD slash YYYY
Location
Denver, CO
Green Bay, WI
Referring Provider's Name
Referring Practice / Clinic Name
Practice Specialty
Practice Phone
Status Of Referral
Routine
Urgent
Emergency
ICD-10 Code(s)
Reason For Referral
Call Us
Consultation
