FIRST APPOINTMENT KETAMINE INTAKE

Ketamine Full Eval and Intake
Name *

First Name Last Name
Date of Birth *

Year Month Day
Date
Email *
example@example.com
Phone Number *

Area Code Phone Number
What are you looking to accomplish? *

Improved well being Improve my relationship with myself Improve my relationship with others Heal from trauma(s) Find peace and acceptance within Process emotions / connect with emotions Find purpose Learn tools to help myself Become more vulnerable Improve Confidence Increase motivation
Have you been struggling with any of the following? *

Decreased Motivation Poor/Negative self talk Inability/Decreased ability to focus Low affect / mood Low energy Irritability Poor sleep quality or duration Excessive worry Chronic Pain Obsessive and/or intrusive thoughts Inability / Diminished ability to control emotions None of the above
Have you considered or received ketamine treatment in the past? *

Yes, but I decided to wait Yes, but it was too costly Yes, and I've received Ketamine treatment before No, but my provider recommended it No, but I've read about the potential benefits No, but a family/loved one recommended it None of the above
Do any of the following apply to you? *

Under the age of 18 years of age Pregnant / Wanting to become pregnant / or Breastfeeding Primary psychotic disorder (e.g. schizophrenia, psychotic disorder unspecified, etc) Bipolar Disorder (currently experiencing mania) Bipolar Disorder (currently experiencing depression or stable mood) Recent drug addiction or substance abuse Uncontrolled high blood pressure (Hypertension) Uncontrolled seizures Untreated / Uncontrolled Thyroid disease (e.g. hyperthyroidism) History of stroke or heart attack Require supplemental oxygen History of heart disease (arrhythmias, congestive heart failure, coronary artery disease) Liver disease AV malformation or aneurysmal vascular disease Active delusions and/or hallucinations N/A
Please list all prior and/or current Neurological/Brain conditions (stroke, epilepsy, concussions, TBI, etc.) *
Have/Are you seeking treatment for any of the following? *

MDD (Major Depressive Disorder) or Persistent depressive symptoms lasting more than 2 weeks Anxiety disorder OCD (Obsessive Compulsive Disorder) PTSD (Post Traumatic Stress Disorder) ASD (an Autism Spectrum Disorder / Asperger's Syndrome) Eating disorder Chronic Pain None of the above
Briefly describe how your chronic pain affects you
Please list any medications as well as what you use them for here *
Please list any medications as well as what you use them for here
Please list any allergies *
Please list any or all anesthesia (surgery) problems with you or your family members

Over the last 2 weeks how often have you been bothered by any of the following problems? *

	Not at all	Several Days	More than half of the days	Nearly Every day
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Trouble falling or staying asleep, or sleeping too much?
Feeling tired or having little energy?
Poor appetite or overeating?
Feeling bad about yourself — or that you are a failure or have let yourself or your family down?
Trouble concentrating on things, such as reading the newspaper or watching television?
Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?

Mania Assessment. Within the last two weeks has there been a time when you were not your usual self and . . .
. . . you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble? *

Yes No
. . . you were so irritable that you shouted at people or started fights or arguments? *

Yes No
. . . you got much less sleep than usual and found you didn't really miss it? *

Yes No
. . . you were much more talkative or spoke much faster than usual? *

Yes No
. . . thoughts raced through your head or you couldn't slow your mind down? *

Yes No
. . . you were so easily distracted by things around you that you had trouble concentrating or staying on track? *

Yes No
. . . you had much more energy than usual? *

Yes No
. . . you were much more active or did many more things than usual? *

Yes No
. . . you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? *

Yes No
. . . you were much more interested in sex than usual? *

Yes No
. . . you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? *

Yes No
. . . spending money got you or your family into trouble? *

Yes No
2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? *

Yes No
3. How much of a problem did any of these cause you - like being unable to work; having family; money or legal troubles; getting into arguments or fights? *

No Problem Minor Problem Moderate Problem Serious Problem
4. Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder? *

Yes No
5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? *

Yes No
Have you ever made any suicide attempts in the past? *

Yes No
Marital Status
Do you currently have a support system in place?

Yes No
If yes, please describe your current support system (Family, Friends, Coworkers, Support Groups, Healthcare Professionals, etc.)
Which treatment type are you receiving? *

In clinic Lifebox (in home)
Your Current Weight (lbs) *Only required for Lifebox*
lbs
How would you prefer to receive your Life Box? *Only required for Lifebox* *

Mail it to me (Shipping costs may apply) I will pick it up
Do you acknowledge that this is a 3 month agreement? *Only required for Lifebox*

Yes No
Driver's License Information *Only required for Lifebox* *

Driver's License Number State Issued Date of Expiration
Take Photo of driver's license *Only required for Lifebox*
Please add any other pertinent health information below *
Ketamine Infusion Center

Our Commitment to You
- We will provide you with the most appropriate care in the most time-efficient fashion.
- We will treat you with respect and professionalism.
- We will always do our best to keep your scheduled appointment and to minimize any wait time you may incur. However, due to circumstances beyond our control, there may be times that we must reschedule your appointment with short notice.
- In order to give you as much notice as possible, we request a phone contact so that we can reach you in person during the day, such as a business number or cell phone.
- We will do our best to move your appointment to an earlier time or date if we have a cancellation in our office schedule.
- If you have any questions regarding this information, please do not hesitate to ask us. We are here to help you.
General Information
- Our office hours are very limited. It is very important that your keep your appointment.
- If you have an emergency and cannot keep your appointment, you must contact our office no later than 48 hours prior to your scheduled appointment date.
- We may charge a NO SHOW FEE if your appointment is not kept or cancelled 48 hours prior to your scheduled time.
- In order to treat you effectively and efficiently and within HIPAA guidelines, we require a registration form and several other forms be completed by you.
- We are sorry, but due to the high fax volume we are NOT able to accept any of the following documents via fax. Without the completed documents, films, tests, and referral, if appropriate, you will NOT be seen by the doctor and your appointment will be RESCHEDULED.
  1. Photo ID
  2. MRI films and reports, CT scan films and reports, bone scan reports
  3. EMG reports
Financial Policy
- We are committed to providing you with the best possible care.
- In order to achieve your maximum allowable benefits, we need your assistance and your understanding of our payment policy.
- Payment is due in full at the time of service, unless you have made payment arrangements in advance with our business office.
Missed Appointments
- Please help us serve you better by keeping scheduled appointments.
- Unless cancelled at least 48 hours in advance , our policy is to charge a NO SHOW FEE for missed office appointments.
I HAVE READ the Financial Policy. I UNDERSTAND and AGREE to this Financial Policy. I GUARANTEE payment of all charges incurred for this account. I hereby assign benefits to Quintessence H&W for all claims submitted to my insurance on my behalf. I further agree to pay any attorney’s fee, court cost, and related collection fees incurred.
PRE-Treatment PATIENT INSTRUCTIONS
- The medicine should be administered with an empty stomach! Do NOT eat (no food, no cereal, nothing) or drink anything (no water, no soda, no coffee, no tea, no Gatorade, nothing) at least 6 hours prior to when the ketamine is administered. Do NOT chew gum or suck on any candy/mint (no gum, no mint, no candy, no cough drops)
- Please continue to take your blood pressure pills, seizure medications, asthma medications, thyroid medication, pain medications as prescribed/scheduled with a sip of water.
- You should have an ESCORT to drive you home due to the nature of the procedure. THIS IS MANDITORY! There can be no driving for a minimum of 6 hours after.
- If in person, please arrive 30 minutes before your appointment time. This allows us time to complete the necessary paperwork and nursing assessments prior to the procedure
- Wear loose fitting clothing the day of your procedure. Consider wearing something that is comfortable but maybe you wouldn't normally wear it.
Female Patients
- If you are pregnant or trying to get pregnant, you MUST inform us immediately.
Diabetic Patients
- If you are a DIABETIC, you need to let us know and we will schedule your procedure early in the morning. Take ½ of your long-acting insulin on the morning of your treatment only. DO NOT take any oral diabetic medications.
- Please, check your glucose (finger stick) at home on day of treatment.
INSTRUCTIONS AFTER THERAPY AT HOME

ACTIVITY
- Take it easy today! REST for 24 hours. Then, increase activity as tolerated. We advise seeking non-stressful and rejuvenating activities post-treatment such as a warm bath, spending time in the sun, listening to calm music, and spending time with a loved one. Low stress is a must for the time after your treatment.
- DO NOT drive any vehicle or DO NOT operate any equipment for 24 hours.
- DO NOT make any important decision for 24 hours.
DIET & MED
- Resume normal diet as tolerated.
- Resume your medications as instructed including pain medication.
- Never discontinue a medication without first consulting your doctor.
Ketamine Infusion Therapy Disclaimer

I wish to participate in Ketamine Infusion Therapy at Quintessence H&W. I understand and acknowledge that Ketamine Infusion Therapy may NOT be covered by either federal or private payors and that my personal healthcare insurance may NOT cover Ketamine Infusion Therapy. Thus, I agree not to make a claim for Ketamine Infusion Therapy with my personal healthcare insurance carrier and further agree and acknowledge that I must pay by cash or major credit card all related healthcare costs related to the Ketamine Infusion Therapy at Quintessence H&W.

By signing below, I accept and acknowledge that I am opting out of using my healthcare insurance for the Ketamine Infusion Therapy and accept paying cash or major credit card for these services.

I understand clearly that Ketamine infusion therapy is NOT FDA approved.

Please note that Quintessence Health and Wellness does not make any guarantees about the results of the information applied on https://quintessencehealthandwellness.com/ or in person in regards to ketamine infusions and/or guidance provided before and/or during and/or after the ketamine treatment. Quintessence health and wellness and their employees including all guides, nurses, and medical practitioners may share educational and informational resources that are intended to help you succeed in your ketamine treatment. You nevertheless need to know that your ultimate success or failure will be the result of your own efforts, your particular situation, and innumerable other circumstances beyond Quintessence Health and Wellness’s knowledge and control.

Quintessence Health and Wellness and their employees do not take any responsibility for the results of your actions, and any harm or damage you suffer as a result of the use, or non-use of the information provided by Quintessence Health and Wellness. Please use judgment and conduct due diligence before taking any action or implementing any plan or practice suggested or recommended by Quintessence Health and Wellness.

Quintessence Health and Wellness do not provide services of a licensed Psychologist, licensed Psychiatrist, or other mental healthcare professionals. Services of guides and/or coaches provided by Quintessence Health and Wellness are merely as a support for the ketamine infusion and do not replace the care of psychologists or other healthcare professionals.
Consents and Authorizations

Consents and Authorizations

I hereby authorize Quintessence Health and Wellness to obtain from any source and examine and use, or discuss and disclose and provide any information necessary regarding the patient with health care practitioners involved in the care of the patient. These communications of information may include unencrypted electronic communications. This authorization to obtain and release information is valid until revoked. The undersigned may revoke this consent in writing at any time, except with regard to information that has already been shared or disclosures that have already been made in reliance on such consent.

Electronic Communications Authorization

I hereby authorize Quintessence Health and Wellness to communicate with me using electronic communications including email, text messages, and voicemail. I may be contacted using the numbers or addresses that I have provided to Quintessence Health and Wellness or that I have used to initiate contact with QH&W. These communications may include appointment information, protected health information and confidential information. I understand that these electronic communications are not encrypted.

Acknowledgment of Review of Notice of Privacy Practices

I have received and reviewed Notice of Privacy Practices. Copy of Privacy Policy available upon request.

Treatment Authorization

I have the legal right to consent to medical and infusion treatment because I am the patient or I am the patient representative. I voluntarily authorize and consent to the medical care, treatment, and diagnostic tests that the providers at Quintessence Health and Wellness and their designees are necessary. I understand that by signing this form, I am giving permission to the doctors, nurses, nurse practitioners, and other health care providers of Quintessence Health and Wellness to provide treatment as long as a physician/patient relationship exists, or until I withdraw my consent.

Agreement to Pay
I understand that I am directly responsible for all charges incurred for medical services for the patient.

I have the legal right to consent to medical and infusion treatment because I am the patient or I am the patient representative. I consent to the procedure(s) or treatment(s) as outlined below to be performed by the medical provider(s) of Quintessence Health and Wellness, their staff, associates, assistants and designees to whom the physician(s) performing the procedure may assign responsibilities.

The proposed procedure(s) or treatment(s) is: KETAMINE IV INFUSION

The procedure(s) or treatment(s) has been explained to me in terms that I understand. The explanation included:

The nature and extent of the procedure to be performed.
- The most frequently occurring risks of the procedure involved, and those risks which are unlikely to occur but which may involve serious consequences.
- The benefits of the procedure.
- The estimated period of incapacity.
- The risks and benefits of any reasonable alternatives to this procedure including having no treatment at all.
I understand that:
- The drugs used and rates of infusion and duration of infusion will vary from patient to patient depending on the appropriate treatment plan for each patient. For a 40 minute infusion there will be a recovery period in the office of approximately 30 minutes. For an infusion with a duration of up to two hours there will be a recovery period of up to approximately 1 hour.
- The use of Ketamine for the treatment of Depression and some other conditions are considered investigational by the Food and Drug Administration.
- Ketamine is considered useful for the treatment of Depression and some other conditions. Effects typically begin within several hours of treatment. It is also possible to have no positive effect from Ketamine infusions.
- Side effects of Ketamine may include dizziness, bad dreams, perceptual disturbances, confusion, elevations in blood pressure, euphoria, dizziness, increased libido and nausea. These side effects typically disappear at the end of the infusion.
- Ketamine is an anesthetic agents and the administration of these drugs is considered anesthesia.
- Complications with anesthesia can occur and include: drug reaction, the possibility of infection, bleeding or injury to blood vessels at the intravenous site. More severe complications could include depression of respiration and heart problems that could lead to serious consequences, including loss of life.
I agree to the Following:
- If applicable, I affirm that I am not pregnant or breastfeeding and that I have no intent of becoming pregnant in the near future. I fully understand the potential for risks to a developing embryo and fetus.
- I agree not to drive a car, operate machinery or make any legal decision within 12 hours after the procedure(s) or treatment(s).
- I am willing to keep myself safe during treatment and in between ketamine infusions.
- I agree to contact 911 in the event that I become suicidal or for any other life-threatening emergency following the procedure(s) or treatment(s).
- I agree to follow up with my referring physician or another licensed medical professional following the course of treatment, and at any time if my conditions worsens.
- I was given the opportunity to ask any questions I have regarding the procedure(s) or treatment(s) and I have had those questions answered to my satisfaction.
- I understand that I may consult or could have consulted with another physician about this procedure(s) or treatment(s).
- I understand that this procedure(s) or treatment(s) is completely voluntary and that I may pursue alternative treatments or no treatment at all for my condition(s).
- I understand that I have the right to refuse this procedure(s) or treatment(s) at any time prior to or during its performance.
- I authorize the physician to perform such additional procedures or treatments, including administering additional medications, which in his/her judgment are incidentally necessary or appropriate to carry out my care.
- If any unforeseen condition arises during this procedure(s) or treatment(s) which requires transportation to a hospital, additional procedures, operation or medication including anesthesia and blood transfusions, I further request and authorize the physician to do whatever he/she deems advisable on my behalf.
- I am aware that the practice of medicine is not an exact science, and I acknowledge that no guarantees or assurances have been made to me concerning the results of this procedure(s).
- I acknowledge that I have read (or had read to me) and fully understand the information on this form. Furthermore, I certify that all my questions and concerns regarding the procedure(s) or treatment(s), its attendant risks, benefits and alternatives have been explained to my satisfaction. I hereby authorize the physician to perform the above discussed procedure(s) or treatment(s).
Emergency Contact *

Contact Name Contact Phone Number
By checking this box you are indicating that you have read and understand the statements / disclosures of this document *

Yes
By providing your Signature you are certifying that you agree to the above statements contained in this document *

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Ketamine Full Eval and Intake