New Patient Form

Full Name*

Date of Birth*

Month

Day

Year

Phone Number*

Email Address*

Address*

Emergency Contact Name and Relationship*

Emergency Contact Phone*

Referral Provider and Phone Number (if applicable)

Current Medications (include dosage and frequency)*

Are you currently under the care of a psychiatrist or pain specialist?*

Yes

No

If yes, please provide name and contact

Have you had previous treatments for your condition? (ex. antidepressants, psychotherapy, ECT, TMS, etc)*

Have you received ketamine treatment before?*

Yes

No

If yes, please describe your experience, location, and outcomes

Do you currently use alcohol, nicotine, or other substances?*

Have you ever been diagnosed with a substance use disorder?*

Yes

No

What are your goals for ketamine therapy?*

How would you describe your current mood and functioning?*

Your dose of ketamine depends on your weight. What is your current weight?

I acknowledge that ketamine is used off-label for mental health and chronic pain conditions.

I understand ketamine therapy is not a cure but may offer symptom relief.

I agree to participate in follow-up assessments and safety monitoring.

I understand that a provider will review my medical history before approving treatment.

Signature*

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Date*

Month

Day

Year