Patient Intake Form

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Patient Intake Form

For optimal user experience, we recommend completing this form on a computer or tablet. If you have any questions about the patient intake form, our staff is available during regular business hours to assist at 1-855-481-9605.

Personal Information

Your Name(Required)
Date of Birth(Required)
Address(Required)
Preferred Method of Contact(Required)
What condition(s) are you seeking treatment for at our clinic?(Required)

Health Information

Have you ever received any form of ketamine therapy (infusions, lozenges, Spravato, etc?)(Required)
If none, type "n/a" or "none"
If none, type "n/a" or "none"
If none, type "n/a" or "none"
If none, type "n/a" or "none"
If none, type "n/a" or "none"
Have you ever experienced any of the following health problems?(Required)

Personal & Lifestyle

If none, type "n/a" or"none"
I am not happy with (check all that apply)
Select all of the following who have the following condition: Depression
Select all of the following who have the following condition: PTSD
Select all of the following who have the following condition: Schizophrenia
Select all of the following who have the following condition: Suicidality
Select all of the following who have the following condition: Drug Abuse
Select all of the following who have the following condition: Alcohol Abuse
If so, please enter their name below so that they may benefit from our referral program.
If so, please list their name/practice below.
By checking this box, I confirm that, to the best of my knowledge, this document accurately reflects my personal health information.(Required)