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Referral Forms

Download the referral form you need below. If you're a patient, ask your doctor to complete the form and fax it to us at (859) 306-0169.

Quick Access to Referral Forms

Click to download referral forms. Can’t find the one you need? Contact us, we’re happy to help!

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- [Download Referral Form] (blank)

Not sure if your treatment is offered?

We offer many other specialty infusions and biologics that may not appear here. If you're looking for a specific treatment, contact us. We’re happy to check availability and walk you through next steps.

Contact Us

Phone: (859) 306-0168         

Fax: (859) 306-0169

Email: info@clarkinfusion.com

For immediate assistance: (317) 504-4295

Note: If you are experiencing a medical emergency, call 911 or go to the nearest emergency room immediately.

Ready to schedule?

Ready to begin treatment? We’d be honored to care for you. Head to the top of our homepage and fill out the form to schedule your infusion and take the next step toward feeling better.

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DISCLAIMER*: Prescription medications require a consultation with one of our licensed healthcare providers. These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease. Please note that individual results may vary, and it is important to follow the guidance of our healthcare professionals for safe and effective treatment. Terms and conditions may apply.

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