Ketamine Clinic Forms
#1.
Informed Consent for Ketamine
#2.
Ketamine
Protocol
#3.
Hamilton Depression Rating Scale (HAM-D)
#4.
FAX's
About
Ketamine
Please Fill Out Forms Prior to Visit
&
Bring The With You :)
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
Address: 861 N. 980 W
Orem, UT 84057