TKC Patient Form

Thanks For Reaching Out.
Let’s start a conversation so we can learn if our ketamine therapy program is right for you. Please answer our brief questionaire

If you are ready, lets begin.

Whats your name*

First NameLast Name
Email *
example@example.com
Phone Number*
Please enter a valid phone number.
Birth Date*

MonthDayYear
AGE

Must be at least 18 years of age to be eligible for ketamine therapy. Unfortunately, we can not move forward at this time.

Medical history, please check all that apply*

I have a known allergy to KetamineI am not currently suffering from depressionI am currently struggling with a significant substance abuse issueI have uncontrolled hypertensionI have not tried and failed at least 2 antidepressant medicationsI have a history of schizophrenia or psychosisI have a recent history of head trauma that is considered unstableI am pregnant or there is a possibility that I will become pregnant during treatmentNone of the above apply
Some conditions preclude your from being able to have ketamine therapy. To look look at the full inclusion/excusion criteria please follow the link below.

If you have any of these conditions unfortunatly, you can not move forward with ketamine therapy at this time.

if you would like to ask a question about any inclusion or exclusion criteria please contact the clinic to speak to one of our helpful and members

416-546-0675

Inclusion and exclusion criteria

Please make sure that you have reviewed Toronto Ketamine Clinics Privacy policy.

Do you live in the province of Ontario?
Residence

YesNo
Non-Ontario residents

Patients who are looking for ketamine treatment who reside outside of Ontario are welcome at TKC. However, every patient that receives treatment at TKC must first get an assessment and approval form a TKC psychiatrist. It is currently the mandate of OHIP and the OMA that these assessments must be conducted within the province of Ontario. Please bare this in mind when making arrangements to get treatment with us. if you have any questions in this regard contact the clinic at 416-546-0675

Please be aware that Ketamine Therapy is not currently covered by OHIP nor ODSP. We are a private clinic, and the treatment is considered an out-of-pocket expense.
You are aware that this treatment is considered out-of-pocket and is not covered by OHIP nor ODSP*

Yes

To access treatment either you General Practitioner or Psychiatrist must fill out and submit a referral form.
Has your care provider submitted a referral form to TKC yet?

YesNo
If your primary care physician has submitted your referral into TKC please contact the clinic and we can schedule your medical assessment. We pride ourselves on making the wait time from referral to treatment a quick as possible.

Clinic phone number is 416-546-0675
Here is a copy of the referral form you can either download it here and send it to you primary care physician to fill it out and email it to info@torontoketamineclinic.com or fax it to 6474177153

The first step to accessing treatment at TKC is getting a referral form submitted. Once this happens, we can get the wheels moving to beginning treatment.

click link here

Referral form

If you would like to know more about ketamine therapy or are ready to get the process started. Please book an appointment to speak to one of our team members. We will help to answer any questions you may have.

Lets start this journey of breaking free from the despair of depression, build back our confidence made unsteady by mental illness and begin to reengage in what can be a beautiful life.
Appointments

Please make sure that you have reviewed Toronto Ketamine Clinics Privacy policy.