Click on each PDF Logo to download each document (1 - 3). Fill them out on your computer or device.
- Clinic Forms -
Family Health & Wellness
In order for Promise Medical to administer Ketamine Muscle Injections (KMI) we need to gather some health background information from you. After the documentation is completed we will have a consultation visit for a physical screening and to review your medical history.
Phone: 385-262-4135 (Main, textable)
801-691-1448 (Alt, not textable)
Fax 801-899-7996
Services:
* cough, sore throat, fever
* sinus infection, ear infection
* COVID testing
* asthma, bronchitis, pneumonia, allergies
* kidney, bladder infections
* skin infection, cellulitis, abscess, accutane
* abdominal pain, back pain
* lacerations
* female health, testosterone replacement
* opioid addiction and suboxone treatment
* physicals (DOT, school & sports, missionary, annual)
* KETAMINE TREATMENT for depression, anxiety, PTSD & chronic pain
* any non-life threatening medical issues
- Ketamine Clinic Forms -
In order for Promise Medical to administer Ketamine Muscle Injections (KMI) we need to gather some health background information from you. After the documentation is completed we will have a consultation visit for a physical screening and to review your medical history.
Download All 3 PDF's to your Desktop
#1.
Informed Consent for Ketamine
#2.
Eligibility Screening for Ketamine
#3.
Hamilton Depression Rating Scale (HAM-D)
Fill them out and bring them with you to your first appointment