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Welcome to Ketamine Healing Clinic! We’re excited to support you on your healing journey. To secure your FIRST appointment, please select the $200 deposit option below. This ensures your spot is reserved and allows us to prepare for your personalized care. We look forward to seeing you soon. — Dr. David Mahjoubi & The Ketamine Healing Team
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Ketamine Healing Clinic of Los Angeles & Orange CountyConsent for Intravenous, Intramuscular, Intranasal, & Oral Ketamine Treatment: Thank you for choosing the Ketamine Healing Clinic of Los Angeles & Orange County.We are honored to be part of your healing journey. Please review the following consent carefully and ask Dr. David Mahjoubi, MD, or a staff member if you have any questions. Complications from ketamine treatment are rare but possible.I. Authorization for TreatmentI hereby authorize Dr. David Mahjoubi, MD, a Certified Registered Nurse Anesthetist, a Registered Nurse, or a Physician's Assistant to administer ketamine via intravenous (IV) or intramuscular route.Ketamine doses used in this clinic are designed to produce conscious sedation—you will not be unconscious, but you may fall asleep especially if you are recieving an infusion for pain managment. I understand that:Ketamine therapy is not a permanent cure for depression, anxiety, PTSD, or chronic pain.Multiple treatments may be required before noticing improvement.Some individuals may not respond to treatment.“Booster” infusions may be necessary to maintain benefits.II. Risks, Side Effects, and ContraindicationsPossible side effects include but are not limited to:Nausea, vomiting, headache, dizziness, constipation, confusion, change in taste or smell, sinus irritation, anxiety, increased blood pressure or heart rate, visual disturbances, or mild dissociation.Serious but rare risks include:Seizure, allergic reaction, urinary or bladder issues, inflammation at the IV site, heart irregularities, stroke, or death.Please inform Dr. Mahjoubi if you:Have a history of seizures, psychosis, mania, paranoia, or substance abuse.Experience sensitivity to alcohol or motion sickness.Are pregnant, breastfeeding, or planning pregnancy (ketamine may cause birth defects).Take medications such as benzodiazepines, Lamictal (lamotrigine), or Keppra—these may interfere with ketamine’s effectiveness.III. Treatment PrecautionsDo not eat or drink for 4 hours before your infusion (sips of water with medications are permitted). 8 hours if you are receiving a pain infusion or infusion longer than 2 hours. Arrange safe transportation; you may not drive yourself home after treatment and until the next day.You must not operate machinery, drive, or make important decisions for at least 24 hours after IV treatment, or 2 hours after oral/intranasal doses (assuming you have following the prescription instructions). If using ride share services (Uber, Lyft, taxi), you release Dr. Mahjoubi and the Ketamine Healing Clinic of Los Angeles, Inc. from any liability related to injury or accident.IV. Treatment Limitations & Follow-UpKetamine therapy is considered an emerging treatment with limited long-term data.Temporary fatigue, insomnia, or emotional discomfort may occur.Some patients may experience “blackouts” or not remember parts of the session.Intranasal and oral ketamine require re-evaluation every 3–4 months per California Medical Board and DEA regulations.Toxicology screening may be required.Dr. Mahjoubi may discontinue treatment if it is deemed unsafe, ineffective, or misused.V. Communication, Appointments, and CancellationsPlease notify us of cancellations at least 2 business days in advance.Missed or late cancellations incur a $200 non-refundable fee.Membership holders: Two no-shows result in the loss of one session.Email communication is used for general correspondence only, not for diagnosis or treatment.Always contact your primary care provider if you are unwell.In case of suicidal thoughts or crisis, go to the nearest Emergency Room or call the Suicide & Crisis Lifeline: 988.VI. Important DisclosuresDr. Mahjoubi is an Anesthesiologist, not a Psychiatrist or Psychologist.If you wish to see one, referrals can be provided.If you are receiving ketamine for pain, contact your pain management specialist for any flare-ups.By signing below, you confirm that you have:Disclosed all medications and substances currently used.Been diagnosed with Depression, Anxiety, PTSD, or Chronic Pain by a qualified provider.Discussed risks and benefits and had your questions answered.VII. Release of LiabilityI understand that despite all precautions, complications may occur, and I hereby release Dr. David Mahjoubi, MD, and Ketamine Healing Clinic of Los Angeles, Inc., DBA Ketamine Healing Clinic of Orange County, from all liability related to injury, loss, or death arising from my participation in this treatment.Patient AcknowledgmentI have read and fully understand the information above.I consent to the administration of ketamine and related medications as deemed appropriate by Dr. Mahjoubi and his staff.*

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I authorize the Ketamine Healing Clinic of Los Angeles, Inc. and DBA Orange County to charge the credit or debit card indicated the amount I have chosen. I certify that I am an authorized user of this credit card, and that I will not dispute the payment with my credit card company so long as the transaction corresponds to the terms indicated in this form and the consent form. I understand there is a 48 hour cancellation policy requiring me to inform the Ketamine Healing Clinic that I cannot keep an appointment. In case of no shows or cancellation within 24 hours, the deposit is forfeited.
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