Elevate - Am I A Candidate

1
What brings you to Elevate Ketamine today?* This field is required.SELECT ALL THAT APPLY
Recover from trauma
Enhance mental clarity
Discover relaxation and tranquility
Boost my self-confidence
Strengthen my relationship with myself
Enhance my connections with others
Better manage stress
Assist me in finding my purpose
2
Which Elevate service are you most interested in?* This field is required.SELECT ALL THAT APPLY
In-clinic infusion treatment
At-home concierge service
Self-administered, at-home treatment delivered
3
Are you experiencing any of the following challenges?* This field is required.SELECT ALL THAT APPLY
Feeling unmotivated
Persistent negative self-talk
Experiencing low energy levels
Difficulty maintaining focus
Struggling with poor sleep quality
Constantly worrying
Suffering from chronic pain syndromes
Engaging in obsessive thinking
None of the above
4
Are you currently taking or have you previously been prescribed medication for:* This field is required.
Depression
Anxiety
Both
Neither
5
Do any of these situations apply to you?* This field is required.
Under 18 years of age
A biological female who is pregnant, nursing, or attempting to become pregnant
A primary psychotic disorder, such as schizophrenia or severe bipolar mania
Recent drug addiction or substance abuse
Uncontrolled high blood pressure
Uncontrolled seizures
History of heart attack, stroke, cardiac or pulmonary disease
Moderate to severe liver disease
AV malformation or aneurysmal vascular disease
None of the above
6
Let's see if trained professionals are in your area. What state are you located in?* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
7
What's your name?* This field is required.
First Name
Last Name
8
What is your date of birth?* This field is required.
Date
Month
Day
Year
9
What is your phone number?
10
What is your email address?* This field is required.
example@example.com
11
How did you hear about Elevate Ketamine?* This field is required.
Healthcare Professional
Referral from friend, family, etc.
Social Media
Google / Search Engine
News / Article
Other
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