I confirm that I am not currently undergoing any other form of Ketamine treatments outside of Evolve Psychiatry. This includes but is not limited to Sublingual ketamine (Mindbloom, Joyous, etc.) or Intravenous Ketamine therapy. If I am receiving treatments from another practice, I am expected to disclose such information to Evolve Psychiatry. If I do not disclose this and use multiple forms of ketamine at once, I am at risk for severe side effects including but not limited to ketamine toxicity, respiratory depression, overdose, and death. I am signing this form acknowledging Evolve Psychiatry’s policy that states no other forms of ketamine will be used by a patient while undergoing Spravato treatments.