Ketamine Healing Clinic Rx Renewal
Complete only if you have received a prescription from us before. If you are receiving a prescription for the first time, stop, and only sign the "At Home Rx Consent" under forms.
Date of Birth
Please enter a valid phone number.
Which form of ketamine are you using:
Both of the above
Are you receiving ketamine from any other provider, physician, telehealth company or clinic? Please note, under our terms of service, you cannot use more than one provider for at home ketamine.
On a daily basis, are you using more than what you have been presribed?
How has Ketamine benefited you? Please check all that apply.
Increase in energy
Increased in mental focus and clairty
It is highly recommended by the Ketamine Healing Clinic that you check a BMP, basic metabolic profile, and LFT, liver function tests including AST and ALT, at least once a year to make sure your blader, kidneys and liver are not affected by Ketamine. This is done via blood draw and can be ordered by your primary care physician or us. If you would like us to do it please email the office. Have you checked you BMP and LFT in the last 12 months?
How often do you use Ketamine?
Approximately half the week
Once per week
A few times per month
You hereby authorize Dr. David Mahjoubi, MD to prescribe you, or the person for whom you are the legal guardian nasal or oral Ketamine. You have been explained the risks of Ketamine in person and have had a chance to ask questions- you wish to receive prescription strength Ketamine for at home use only. Ketamine carries risks including but not limited to: increased urination, headache, constipation, nausea, vomiting, discomfort, change or loss of taste sensation, change or loss of smell sensation, sinusitis, changes in urination or possible bladder or kidney injury, and allergic reactions. Prescription strength medications, while considered safe, carry the risk of heart irregularities, heart attack, stroke, seizure, brain damage or death. Rarely, nausea and/or vomiting may persist for weeks or months. Loss of weight, nightmares, and abnormal sweating associated with the sensation of heat for a month or more can happen after receiving Ketamine. Ketamine may also worsen a psychotic disorder if one is present- please let the doctor know if you have a history of substance abuse or psychotic disorders. Rarely, Ketamine can trigger a seizure. Please let the doctor know if you have a history of seizures, have stopped drinking alcohol or taking benzodiazepines, or think you may have had a seizure in the past. By signing this document, you attest to have been diagnosed with depression, anxiety, or PTSD by a certified mental health expert (or pain by a physician) who uses appropriate diagnostic criteria, that you have disclosed any history of substance abuse, and that you have disclosed any history of psychotic episodes/disorders or seizures. In order to ensure continued compliance with the DEA and Medical Board of CA regarding at-home Ketamine therapy, we must either see you in person, or recieve this document you are signing, every 3 months (or whenever you are out of refills). Early refills are not allowed before 30 days and ensure ketamine is not being overused. We reserve the right to cancel any prescription refill pending the results of a urine toxicology screen, or for any other reason. Ketamine via the nasal or oral route can cause prolonged drowsiness, therefore, you must not drive within two hours of using Ketamine at home, assuming you have used the Ketamine according to the instructions on the prescription. If you have used more than what has been prescribed, you must refrain from driving or operating heavy machinery for 24 hrs. You release Dr. David Mahjoubi and the Ketamine Healing Clinic of Los Angeles, Inc., of all liability in the event of a vehicular accident or bodily or psychological injury or harm. Ketamine at home in oral or spray form may cause birth defects to your fetus, it is your responsibility to inform Dr. Mahjoubi and the office if you are or may be pregnant, or if you are trying to get pregnant. By signing this form, you release Dr. David Mahjoubi, MD, and Ketamine Healing Clinic of Los Angeles, Inc. of all liability related to birth defects or reproductive harm to you or your fetus. There is no guarantee for relief of depression, PTSD, anxiety, or chronic pain. Dr. Mahjoubi is an Anesthesiologist, not a Psychiatrist or Psychologist- if you wish to see one please inform him so that he can refer you to one. Rarely, insomnia, fatigue, dysphoria, stress, or anxiety may occur with intra-nasal or oral Ketamine. Additionally, some individuals “black out” or do not remember anything. Please lessen your usage if you find that you are faint, cannot remember as well as before, or experience any other side effects following use. Please stop usage if you find you are craving Ketamine, or think you are addicted to Ketamine, and let Dr. Mahjoubi know as soon as possible. It is important that you do not sign important documents within 12 hours of each dose of intranasal or oral Ketamine. Please exercise caution and do not take more than that which is prescribed to you. If you are feeling dizzy, you must sit or lay down, and stop what you are doing. While intranasal or oral Ketamine does benefit many people, every individual responds differently, and not everyone will gain immediate or long- term relief from Depression, Chronic Pain, or any other mood irregularity. Always seek the help of your primary care provider if you are feeling unwell or sick. If you have made plans to commit suicide, please go to the closest Emergency Room before using Ketamine. The Ketamine Healing Clinic of Los Angeles or Orange County does not diagnose any condition- thus we are unable to fill out or sign any documents for disability benefits on your behalf. Such requests should be made to the physician that provided you with the initial diagnosis. Your agreement to the terms and conditions signifies that all questions have been answered to your satisfaction, that you fully understand the risks involved with nasal or oral Ketamine, or ketamine in any form, and you agree to all aforementioned statements contained in this document. You understand that no warranty or guarantee of a result or cure has been made. Should you feel depressed despite ketamine therapy in any form, please contact your mental health expert such as a licensed psychiatrist or psychologist. If you have a pain flare up and are receiving ketamine for pain, contact your pain management doctor. If you do not have a provider, contact your primary care physician, or go to the nearest emergency room, or text/call 988 the national suicide hotline. You are aware that this office conducts a check on CURES, the Department of Justice website, to ensure patients are not using more than one provider to receive ketamine.
On a scale of 0-100, please rate the extent to which Ketamine has helped you, with 100 being the most help, and 0 being not at all.
Do you feel you are addicted to Ketamine?
Please list all medications that you are taking, including dosages. This includes prescriptions as well as over the counter medications. If there have been no changes since your last Rx Renewal with us, you may write "No changes since my last evaluation by the Ketamine Healing Clinc."
Do you use any of the following:
Opiates including Fentanyl
Other illicit drug(s)
None of the above - I don't use any substance to get high or self-sooth.
If the answer is Yes to any of the above, please write how often:
Which pharmacy do you prefer we send your prescription to? Please note a change in pharmacy does not mean an early refill is possible.
Do you have any new medical diagnosis since your last Rx renewal or in person evaluation:
Yes - If Yes, please email the doctor at firstname.lastname@example.org with your new medical diagnosis.
Have you had surgery since your last Rx renewal or in person evaluation:
Are you experiencing any side effects that you believe are due to at home Ketamine therapy? If you do not please write "No."
( X )
Consult for Rx Refill
Credit Card Number
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Should be Empty: