Name *

First Name

Last Name

Phone *

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Are You a New Patient? *

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Todays Date *

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Reasons For Seeking Ketamine Assistance:

PTSD

Depression

OCD

History of Trauma

Spritiual Exploration

Grief

Suicidal Ideation

Are You Currently Experiencing Any Of The Below ?

Uncontrolled Bipolor Disorder

Acute Mania

Active Substance Abuse

Uncontrolled Hypertension

Uncontrolled Coronary Artery Disease

Uncontrolled Hyperthyroid Disease

Acute Psychosis