Ketamine Treatment Informed Consent*
This field is required. By electronically signing Choose Ketamine's Ketamine Treatment Informed Consent, I confirm that:
1. I have fully read and understand this agreement. I understand the potential benefits, risks, and alternative treatment options, and I freely give my consent to participate in ketamine treatment and receive services via telehealth from third party providers associated with Choose Ketamine.
2. I will abide by all of Choose Ketamine's guidelines and requirements outlined in this agreement and/or those that have been communicated by my Choose Ketamine clinician.
3. I meet the eligibility criteria and do not meet the exclusion criteria listed in the "Eligibility" section of this agreement. If there are any changes to my physical or mental health that impact my eligibility for treatment, I will notify my providers immediately and discontinue treatment, if necessary.
4. I understand that Choose Ketamine providers are notable to connect me directly to any emergency services. If I am in a life-threatening situation, I will call the National Suicide Prevention Line at +1-800-273-8255, call 911, or go to the nearest emergency room.
5. I understand it is up to the Choose Ketamine provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
6. I understand that my healthcare information may be shared with other individuals for the purposes of treatment, scheduling, billing, and other healthcare operations.
7. I give Choose Ketamine's providers permission to access information regarding my historical medical data through their electronic health record system.
8. I understand that if I participate in a consultation, I have the right to request a copy of my medical records.
9. I understand that I may withdraw from treatment and/or the use of telehealth at any time.
10. I have had the opportunity to review this agreement with my clinician and ask questions, and I have received satisfactory answers to my questions.