Patient Forms

Forms 2018-06-28T01:29:26+00:00

Ready for treatment that works? Fill out these forms before your appointment so we can begin your screening without delay. If you wish to fill the forms out in the office instead, please arrive 15 minutes before your appointment time.

Patient Intake Form

Answer questions about your medical history fully to help us come up with a safe and effective treatment plan.

Ketamine Fact Sheet

Download the fact sheet for information about ketamine. Please keep in mind that the dosage used for ketamine infusion therapy is far lower than the FDA-approved amount described in this packet.

Depression Inventory

How are you feeling right now? Fill out this form before treatment so we can track your progress.

Medical Records Release Form

Your privacy is important, and protected by law. Let us know who can access your records.

Ketamine Infusion Centers Referral Letter

Download the Ketamine Infusion Centers Referral Letter.