Enquiry form
For patients
Are you aged between 20 - 65?
*
Yes
No
Are you pregnant?
*
Yes
I'm not sure
No
Date of Birth
*
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
E-mail
*
How best to contact you?
*
Please Select
Phone call
Zoom call
Email
Mail
Other
Please Specify
*
Do you prefer seeing us remotely?
Yes
No
No preference
Do you have a GP?
*
Yes
No
Please Specify
*
GP name and practice
Do we have consent to contact your GP for additional information (only if necessary)?
*
Yes
No
Why are you seeking treatment?
*
Please contact LIFELINE 0800543354 if you do not feel safe.
Have you tried at least THREE medications with poor response?
*
Yes
No
Why not?
*
No access
Never offered
Poor tolerance
I do not believe in them
List the medications you have tried:
*
Please tick the following conditions if it applies to you:
Allergy to ketamine
Substance abuse
Bladder or kidney problems
Intellectually disabled
Chronic hypertension
Psychosis or Schizophrenia
Please list other medical conditions (if any):
Submit
Should be Empty: