NutraBrain Protocol
If you have any questions prior to booking below, please call or text us at 949-514-8261, or email supportoc@ketaminehealing.com.
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Are you physically located in, or are you able to do the video consultation from, California, Utah, or New York? If not, please stop and do not submit this form as you are not located in one of our licensed states. You must do the video consultation from one of the aforementioned states.
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If any of the following apply to you, please stop what you are doing and do not proceed:
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Under 18 years of age
Have had a psychotic episode in the past
Hear or see things other people dont
Diagnosed with Schizophrenia or Schizoaffective disorder
Have a history of addiction to ketamine
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Have thought of killing yourself or have a plan to kill yourself
Are not able to have a trusted friend or relative with you during the first session
Have extreme lower abdominal pain
Have incontinence
NONE OF THE ABOVE
The Ketamine Healing Clinic of Los Angeles and Orange County conducts a monthly state wide as well as interstate check of all controlled substances prescribed to each individual receiving a prescription for Ketamine. You understand that using more than one doctor, or company/online service, to receive Ketamine will result in permanent termination of your prescription throught the Ketamine Healing Clinic of Los Angeles, Inc and reporting to the other doctor/service.
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Consent for At-Home Ketamine: You hereby authorize Dr. David Mahjoubi, MD and the Ketamine Healing Clinic of Los Angeles, Inc. to prescribe you oral Ketamine. You have been explained the risks of Ketamine 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 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 to us. Ketamine can cause prolonged drowsiness, therefore, you must not drive within 4 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 may cause birth defects to your fetus- thus 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. Long term abuse of ketamine may result in schizophrenia-like symptoms. 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 24 hours of each dose of 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 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 or call 911. The Ketamine Healing Clinic of Los Angeles 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. Please note the FDA alert and official position on compounded Ketamine: "Compounded Ketamine is not approved for any psychiatric disorder or mood treatment.
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You agree to have a trusted person with you for your first session. If you have a history of hypertension, stroke, or heart attack, you must inform Dr. Mahjoubi during your consultation and use a blood pressue monitoring device during your Ketamine NutraBrain sessions. If you have a history of COPD or Emphysema, you must inform Dr. Mahjoubi and a pulse oximeter must be used when using ketamine. Rarely, "ketamine bladder" may occur with abuse and excessive use of Ketamine. You agree to stop using Ketamine if you become incontinent or have pain in your lower abdomen (please note Dr. Mahjoubi has never had a patient develop this condition). If you are unfamiliar with these types of medical monitoring modalities or symptoms, please ask us before proceeding at the number found at the top of this form.
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*Ketamine has been prescribed to me on a trial basis. There is a small risk that ketamine addiction can occur. Almost always, this occurs in patients with a personal or family history of other drug or alcohol abuse. If it appears that I may be developing addiction, my doctor may determine to end the trial. Taking ketamine with other prescription drugs or substances may result in death. Taking Ketamine in a bath tub or jacuzzi, or going into a bath tub or jacuzzi, after using Ketamine can result in death. Only use Ketamine while sitting in a safe and secure area in your home. Do not use more than that which is prescribed to you on a daily basis.
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I understand the Ketamine Healing Clinic does NOT cover the cost of the prescription (as this is unlawful), and agree to use the pharmacy where the prescription is called into by Dr. David Mahjoubi. I may use any other pharmacy as long as I email the Ketamine Healing Clinic the address and contact information of the pharmacy (Please note it must be a compounding pharmacy). I agree to the Ketamine Healing Clinic of Los Angeles Terms of Use and Privacy Policy.
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First Month NutraBrain Protocol
If you have never received Ketamine from NutraBrain, you must choose this option.
$
400.00
Second Month NutraBrain Protocol
Only applies if you have completed the first months protocol with us.
$
375.00
Third Month NutraBrain Protocol
Only applies if you have completed the first two months of the NutraBrain protocol.
$
350.00
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Patient Instructions for using Ketamine at home. Please download.
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.
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Yes
You are aware that prolonged Ketamine use may cause damage to the lining of the bladder and bladder dysfunction. Long term studies on the prolonged use of Ketamine have not been done.
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