Patient Forms

New Patient Forms

Download, print, and fill out these forms to bring with you to your first appointment.

Patient Information Form
Patient Health History & Current Medication List
General Consent for Care & Treatment
Controlled Substance Agreement

Ketamine Clinic Forms

In order to administer Ketamine Muscle Injections (KMI) we need to gather some health background information from you.

Informed Consent for Ketamine
Eligibility for Ketamine Treatment
Hamilton Depression Rating Scale (HAM-D)
FAQs About Ketamine

Anxiety & Depression Forms

If you are struggling with anxiety or depression, please bring these forms with you to your appointment.

PHQ-9 Form
GAD-7 Form

DOT Form

Download and fill out this form then print it out and bring it with you to your DOT Exam.

DOT Form MCSA-5875