Informed Consent for Ketamine Therapy Ketamine is approved by the FDA for use in children and adults for anesthesia and as a pain reliever during medical procedures. When administered orally, ketamine is a medication that may provide relief of symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), acute and chronic pain. Ketamine’s use for treatment of pain, depression or other mental illnesses is off-label. Off-label use of medications is legal and very common. In fact, about one in five prescriptions written in the US today is off-label.

Why Is Ketamine Being Recommended? Numerous studies show that ketamine may be helpful in the treatment of depression, anxiety, PTSD, acute and chronic pain. When administered, ketamine may help improve symptoms rather quickly. Orally, sessions last around 2-5 hours. Improvements may last several days up to a few months. A series of oral treatments are recommended so that symptom relief has a longer duration of action. WHILE THE GOAL IS IMPROVEMENT OF SYMPTOMS, INDIVIDUAL RESULTS CANNOT BE GUARANTEED.

What Will Be Done? You will be receiving ketamine orally. This means you will take the ketamine orally at home with a sitter or in office. After the treatment, you will need time to recover and may take some sips of fluid during the recovery period. After the initial induction phase of about four weeks, additional maintenance treatments may or may not be suggested, occurring about once a month or less frequently as recommended by your infusion provider. 

What Safety Precautions Must You Take?  You may NOT drive a car, operate hazardous equipment, or engage in hazardous activities for the rest of the day after each treatment as reflexes may be slow or impaired. Another adult will need to drive you home and must be present prior to your discharge.  You may not eat or drink 4 hours before the treatment, water is the only exception to take nausea medication and wash down the ketamine.  You must tell the clinic about all medications you are taking, especially narcotic pain relievers, benzodiazepines, barbiturates, and muscle relaxers.  Please take your scheduled medications the night before treatments. On the day of treatments, hold all benzodiazepines and ADHD medications until after the treatments.  You must refrain from alcohol 24 hours prior-to and following ketamine administration. You must refrain from other illegal substances during your ketamine treatment.  To qualify to receive ketamine therapy for mental health conditions, you must notify and share the contact information for the mental health provider treating your psychiatric symptoms or your current primary care provider.  If you experience a minor side effect while you are at home, you should contact the Padgett at (813-888-7710)  If you experience a major side effect or have thoughts of harming yourself, call 911.

What Are the Possible Side Effects of Ketamine? Possible side effects may include and are not limited to:  fast or irregular heart beats  increased saliva or thirst  increased or decreased blood pressure  lack of appetite  vivid dreams  headaches  confusion  metallic taste  irritation or excitement  constipation  floating sensation (“out-of-body”)  blurry or double vision  twitching, muscle jerks, and muscle tension  confusion  urinary frequency  nausea or vomiting  memory changes Rare side effects of ketamine are:  allergic reactions  hallucinations  pain at site of injection  euphoria  increase in pressure inside the eye  involuntary eye movements  inflammation in the bladder  suicidal thoughts  respiratory complications  

My Consent for Ketamine Treatment is Voluntary:
My request for ketamine treatments as described is entirely voluntary and I have not been offered any inducement to consent. I understand that I may refuse ketamine treatments at any time.

I have been advised that I can seek a second opinion from another provider before agreeing to have ketamine treatment and I am choosing to proceed at this time, with or without this second opinion. 

Statement of Person Giving Informed Consent
 I have read this consent form and understand the information contained in it. I
understand the risks and benefits and have had the opportunity to have all my questions
answered to my satisfaction.
 I have had the opportunity to ask questions about this procedure. I consent and would
like to proceed with ketamine infusion treatment.

Ketamine Sitter

Your ketamine sitter must be 18 years of age or older and able to stay with you the entire time during your session.  This person will help you use the restroom, be supportive during your session, and possibly help you process emotions that come up during treatment.  

A ketamine therapy sitter is a friend or loved one who ensures your emotional and physical safety during the ketamine experience. The sitter provides a caring presence, maintains the physical environment, and assists as needed so you can achieve optimal results. Witnessing the changes in thought patterns and emotions that occur during the ketamine journey can be very rewarding for the sitter.

What to do during your session: During your session we recommend laying down somewhere comfortable such as a bed or recliner. You will use eye shades and headphones to listen to spa music as your journey takes place. We recommend a clear pathway to the restroom and to make sure your sitter is in the same room during your session. After the session is over you will be groggy and unable to drive, operate machinery, or sign any legal documents for the remainder of the day.

Patient Rights and Responsibilities

Welcome to Padgett Medical Center. Our goal is to provide quality health care to persons in this community. As a patient, you have rights and responsibilities. The clinic also has rights and responsibilities. We want you to understand these rights and responsibilities so you can help us to provide health care for you. Please read this statement and inform us if you have any questions. Human rights You have the right to be treated with respect and dignity regardless of race, religion, sex, or national origin. Payment for services You are responsible for all payments at time of visit. Please ask an associtate Privacy You have the right to have interviews, examinations, and treatment in privacy. Your medical records are also private. Only legally authorized persons will have access to your records.  You are responsible for providing us accurate, complete, and current information about your health so that we can provide you proper treatment. You have a right and are encouraged to participate in decisions regarding your treatment. You have the right to information and explanations in the language you normally speak and in words you understand. You have a right to information about your health or illness, treatment plan (including risks), and expected outcome, if known. If you do not wish to receive this information, or if it is not medically advisable to share that information with you, we will provide it to legally authorized persons. If you are an adult, you have the right to refuse treatment to the extent permitted by law, and to be informed of the risks of refusing. You are responsible for the outcome of refusing treatment. You have the right to health care and treatment that is reasonable for your condition and within our capacity. You have a right to be transferred or referred to another facility for services that we cannot provide. However, we (Padgett Medical Center) are not financially liable for any additional costs incurred. You have a right to the appropriate assessment and management of your ketamine treatment within the available resources of the clinic.

Clinic rules

You have the right to receive a copy of your patient information, health services we provide, personal conduct polices, and the use of our property and resources. You are responsible for obeying these rules. You are responsible for appropriate use of our services, which include following our staff’s instructions, and making and keeping scheduled appointments.

If you do not change your appointment a minimum of 24 hours in advance, you will be charged a $25 fee. This will hold true for every time you change an appointment. If you are more than 15 minutes late for your appointment, you will be charged a $25 fee that same day. If we have not heard from you by 30 minutes past your scheduled appointment time, you will be considered a no show and lose your slot. You are responsible for the supervision of children you bring into the clinic. You are responsible for their safety, as well as the protection of others and our property. You may not smoke or loiter on the property. This includes the entire professional plaza. In an effort to be in good standing with our neighbors and the landlord, we ask you refrain from having anyone, family, friend, pets, etc., waiting in a car while you are here. You may bring one (1) additional person inside with you as you wait for your appointment. Please ask anyone else to come back after the appointment is over. Inappropriate conduct by the patient or anyone accompanying the patient will not be tolerated. Profanity, disorderly conduct, threats of violence, or acts of violence will result in the discharge of the patient from our facility. You, as the patient, are responsible for the actions of your guests. Please bring everything requested by the doctor and staff to your appointment. 

Hours of operation: Monday through Friday 9am – 5pm, except on major holidays. For after-hours emergencies, please go to the nearest emergency room. We do not accept walk-in patients. To schedule an appointment, please call that specific facility.

Ocala – (352) 369-0104 Tampa – (813) 888-7710

Medical records Any request for copies of medical records takes 24 hours minimum. There is a charge for copies of your record ($1 per page for the first 25 pages, $0.25 per page for pages 26 and after). Please ask a staff member for a page count prior to requesting the full record be copied. Any request for billing statements take a minimum of one (1) week. The doctor has to review any statement before it is sent out. Please allow appropriate time when asking for this service. If records need to be sent with the statement, see above.

Patient Rights and Responsibilities Acknowledgement I acknowledge that I have read and received a copy of the Patient Rights and Responsibilities. I agree to follow and obey the rules and regulations set forth by Padgett Medical Center, LLC.

NOTICE OF PRIVACY PRACTICES 
This notice describes how medical/protected health information may be used and disclosed and how you can get access to this information. Please review carefully. 
 
SUMMARY: 
By law, we are required to provide you with our Notice of Privacy Practices (NPP). This Notice describes how your medical information may be used and disclosed by us. It also tells you how you can obtain access to this information. 
 
As a patient, you have the following rights:  
The right to inspect and copy your information 
The right to request corrections to your information 
The right to request that your information be restricted 
The right to confidential communications 
The right to report a disclosure of your information 
The right to a paper copy of this form 
 
We want to assure you that your medical/protected health information is secure with us. If you have any questions regarding this form, please contact one of the office staff at Padgett. 
 
I hereby acknowledge that I have read this copy of NOTICE OF PRIVIACY PRACTICES. I understand that if I have a question or complaint regarding my privacy rights, I may contact a member of the staff at Padgett Medical Center. I further understand the practice will offer me updates to the NOTICE OF PRIVACY PRACTICES should it be amended, modified, or changed in any way. 
 

HIPAA (Health Insurance Portability and Accountability Act) Information Release & Disclosure Notice 
This notice describes how health information about you may be used and disclosed, and how you can get access to this information. Please review it carefully. 
Purpose 
Padgett Medical Center, LLC and its faculty, employees, and non-employees follow the privacy practices described in this Notice. Padgett Medical Center maintains your health information in records that are kept in confidential manner, as required by law. Padgett Medical Center must use and disclose or share your health information as necessary for treatment, payment, and health care operations to provide you with quality health care. 
Use and Release of Your Health Information for Treatment, Payment, and Health Care Operations 
Padgett Medical Center has to use and release some of your health information to conduct its business. We are permitted to use and release health information without authorization from you. Treatment includes sharing information among health care providers involved in your care. For example, your health care provider may share information about your condition with radiologists or other consultants to make a diagnosis. Padgett Medical Center may use your health information as required by your insurer to determine eligibility or to obtain payment for your treatment. In addition, Padgett Medical Center may use and disclose your health information to improve the quality of care, and for education and training purposes of Padgett Medical Center residents, and faculty. 
How will Padgett Medical Center Use and Disclose My Health Information? 
Your health information may be used for the following purposes unless you ask for restrictions on a specific use or disclosure. Note: You have the opportunity to refuse some of these communications about your health information. The optional items are indicated by (*). Please let a staff member know if you wish to refuse any or all of the optional communications. 
(*) Padgett Medical Center directories, which may include your name, general condition, and your location in Padgett Medical Center.  
(*) Family members or close friends involved in your care or payment for treatment.  
(*) Disaster relief agency if you are involved in your care or payment for treatment. 
(*) To inform you of treatment alternatives or benefits or services related to your health. 
Appointment reminders. 
Public health activities, including disease prevention, injury or disability; reporting births and deaths; reporting reactions to medications or product problems; notification of recalls; infectious disease control; notifying government authorities of suspected abuse, neglect, or domestic violence. 
Health oversight activities, such as audits, inspections, investigations, and licensure. 
Law enforcement, as required by federal, state, or local law. 
Lawsuit and disputes, in response to a court or administrative order, subpoena, discovery request or other lawful request. 
Coroners, medical examiners, and funeral directors. 
To prevent a serious threat to health or safety. 
To military command authorities if you are a member of the armed forces or a member of a foreign military authority. 
National security and intelligence activities to authorized persons to conduct special investigations. 
Workers’ Compensation. Your medical information regarding benefits for work-related injuries and illnesses may be released as appropriate. 
To carry out health care treatment, payment, and operations functions through business associates, such as to install a new computer system. 
Your Authorization Is Required for Other Disclosures. 
Except as described above, we will not use or disclose your medical information, unless you allow Padgett Medical Center in writing to do so. You may withdraw or revoke your permission, which will be effective only after the date of your written withdrawal. 
Alcohol and drug abuse information has special privacy protections. Padgett Medical Center will not disclose any information identifying an individual as being a patient or provide any health information relating to the patient’s substance abuse treatment unless the patient authorizes in writing; to carry out treatment, payment, and operations; or, as required by law. 
You Have Rights regarding Your Health Information. 

You have following rights regarding your medical information, if requested on the form(s) provided by Padgett Medical Center: 
Right to request restriction. You may request limitations on your health information that we use or disclose for health care treatment, payment, or operations, although we are not required to comply with your request. For example, you may ask us not to disclose that you have had a particular procedure. We will release the information if necessary for emergency treatment. We will notify you in writing whether we honor your request or not. 
Right to confidential communications. You may request communications of your health information in a certain way or at a certain location, but you must tell us how or where you wish to be contacted. 
Right to accounting of disclosures. You must request a list of the disclosures of your health information that have been made to persons or entities for disclosures unrelated to health care treatment, payment, or operations within the past six (6) years for paper health records, and for electronic health records you may request three(3) years, including disclosures for treatment, payment, or operations. After the first request, there may be a charge. 
Right to a Copy of This Notice. You may request a paper copy of this Notice at any time, even if you have been provided with an electronic copy. You may obtain an electronic copy of this Notice in our office. 
Requirements Regarding This Notice. 
Padgett Medical Center is required by law to provide you with this Notice. We will comply with this Notice for as long as it is in effect. Padgett Medical Center may change this Notice and these changes will be effective for health information we have about you as well as any information we receive in the future. Each time you register at Padgett Medical Center for health services, you may receive a copy of the Notice in effect at that time. 
Complaints 
If you believe your privacy rights have been violated, you may file a complaint with: 
Office of Civil Rights 
U.S. Dept. of Health and Human Services 
200 Independence Avenue, S.W. 
Washington, DC 20201 
Contact Padgett Medical Center at (352) 369-0104 or (813) 888-7710 if: 
You have any questions about this Notice; 
You wish to request restrictions on uses and disclosures for health care treatment, payment, or operations; or 
You wish to obtain a form to exercise your individual rights.Page Break 
 
HIPAA Information Release & Disclosure Notice Consent 
I acknowledge that I have read, received, and understand this HIPAA notice and may request a copy at any time.