Patient Questionnaire - Ketamine Assisted Therapy

Patient Questionnaire - Ketamine Assisted Therapy

Ketamine Healing Clinic of Los Angeles & Orange County / supportoc@ketaminehealing.com / 949.514.8261
Are you physically located in California, New Jersey, Virginia, Massachusetts, Illinois, Wisconsin, Texas, New York, Connecticut, New Mexico or Utah? If not, stop and do not proceed as you are not in one of our licensed states.*
Name*

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Are you 18 years old or over?*

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Address

Street Address

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CityState / Province

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Do any of the following apply to you?*

Have a plan to commit suicideHear or see things other people do notDiagnosis of SchizophreniaPlans to commit violence against othersCurrently using "street" or prescription KetamineAcute ManiaHistory of psychotic break down or psychosisNone of the above
Please check off any of the diagnosis that apply to you:*

DepressionAnxietyPost Traumatic Stress DisorderObsessive Compulsive Disorder
Have you been diagnosed with any of the following conditions?*

High Blood Pressure aka HypertensionChronic Obstructive Pulmonary DiseaseSleep ApneaUse of CPAP machineUncontrolled blood pressureCongestive Heart FailureBreathing DifficultiesPregnant, attempting to become pregnant, breast feedingUncontrolled Glaucoma or high pressue in the eye(s)Compromised liver or kidney functionNone of the above
My Products*
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Video Consultation with Dr. David Mahjoubi
You must complete three video consultations before qualifying for our automatic refill program, after which a video consultation is not needed for 12 months.

$400.00

Total

$0.00
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
The following consent is for at-home therapy with Ketamine in any form and taken via any route. The Ketamine that will be prescribed to you is a controlled substance. It is important that you do not drive a vehicle, operate heavy machinery, give your consent, or sign important documents within 4 hours of each dose of intranasal Ketamine you self-administer, assuming you have followed the prescription instructions. In the event that the usage of Ketamine results in the loss of life, limb, or monetary loss, you release Dr. David Mahjoubi, MD and Ketamine Healing Clinic of Los Angeles, Inc., from all liability. 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. Ketamine is not a cure for any condition. At some point you will need a maintenance aka “booster” infusion-the time period to that point significantly varies between patients and is impossible to predict. Due to California Medical Board and DEA guidelines, the Ketamine Healing Clinic must evaluate you either in person or via an online evaluation every 3-4 months to continue prescribing the controlled substance Ketamine for at home use. We are required by law to run a background check for controlled substances prescribed every time we grant refills, as well as update our records with your health history and any concomitant changes. Such reevaluation may include submitting a urine and/or blood toxicology screen. This takes time and this, in addition to the increase cost of supplies, wages, etc are the reason for the renewal fee. If you are receiving Ketamine from this clinic, infusions must be done at this clinic as well. Dr. Mahjoubi reserves the right to discontinue intranasal or oral Ketamine therapy if he deems such therapy to be ineffective, addictive, or for any other reason. Rarely, usage of oral or nasal Ketamine may cause transient or permanent changes to your ability to taste, smell, or urinate. Other changes reported “online” but not seen by Dr. Mahjoubi include changes to visual, bladder or kidney function. It is required that every patient that is prescribed at home ketamine complete a yearly laboratory work: CBC, CMP, and liver function tests. PRESCRIPTION REFILLS DIRECTIONS: Please allow up to 3 business days for your request to be processed and also allow up to 3 business days for a reply to your email. • For refills, please reach out to your pharmacy directly. Please have the pharmacy send an “electronic request” or email nurse@ketaminehealing.com • Early refills due to travel are not an emergency and should be planned well in advance (at least 7 days prior to your departure day). If you are traveling in between refills dates you are not eligible for an early refill (e.g. your refills dates are April 1 and May 1, and you are traveling April 5-25). Refills are processed during regular business hours on weekdays only, and getting an early refill due to travel does not change subsequent refill dates. • If there are 0 refills left on your prescription- if a consultation is required and you do not want to complete an infusion, please fill out the Rx Renewal found on the ketaminehealing.com website under “Forms." Please plan ahead of time with refills as there can be one week or more turn around time. By signing below you agree to the following: I understand that my physician is prescribing a controlled substance medication as a part of my treatment plan. I will not take controlled substances written by another provider or specialist unless I have notified my provider prior to filling the prescription. I agree to safekeeping my controlled substance. I understand that lost, misplaced, or stolen prescriptions will not be replaced and/or refilled early. I will not share, exchange, or sell my controlled substance, as the law prohibits those actions. I understand that my provider reserves the right to report serious concerns of drug misuse to any and all authorities for investigation. I understand that combining controlled substance medication such as Ketamine with consumption of alcohol or any other drugs/medications can be life threatening or endanger my health. I understand, that due to Medical board of CA and DEA guidelines, I must complete a re-evaluation every 3 months for controlled substance refills by either completing our online Rx Renwal form or scheduling an in-office treatment. I understand that getting laboratory work to check complete metabolic profile and liver function every six months or at least once a year is needed to ensure Ketamine is not affecting my liver, kidney, or any other organs. I will not lie or tell misleading information to my provider. I understand that random drug screen may be performed by the Ketamine Healing Clinic of Los Angeles or Orange County. I understand the risks, benefits, and safety of controlled substance such as Ketamine including. I understand that the Ketamine Healng Clinic of LA may reserve the right to discontinue Ketamine prescription for any reason including but not limited to abuse or excessive use of Ketamine. Obtaining Ketamine from another doctor is grounds for discontinuation of the treatment. I have read and understand the terms of this contract and I have had an opportunity to ask questions about the use and disclosure of my health information. With my signature below, I hereby, knowingly and voluntarily, promise to follow the regulations of the contract. Please note that the FDA does not approve of compounded ketamine for any psychiatric disorder or diagnosis.*

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Your therapists name: *
Patient instructions for using Ketamine with your therapist:
You understand that using more than one doctor or company to receive prescriptions for Ketamine will result in permanent termination of your prescription through the Ketamine Healing Clinic of Los Angeles, Inc, without any refund for consultations completed. You are also aware that studies on the long term use of Ketamine have not been done, and there is a risk for damage to the bladder and/or other organs with Ketamine usage. *

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You understand that long term studies on Ketamine use have not been done and that injury to your bladder or any organ may result from prolonged used of Ketamine. *

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