New Patient Intake Form

Name

First NameLast Name

Date of Birth

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

How did hear about us/find us?

Insurance Information

Provide a Photo of Your Insurance Card (Front)

Provide a Photo of Your Insurance Card (Back)

Insurance Policy

I understand that I am responsible for payment for services rendered by KETALINK Ketamine Center and that confirmation of insurance benefits is not a guarantee of payment and that I am responsible for any unpaid balance.

If my insurance becomes inactive or if it otherwise denies coverage for services, I understand that I am responsible for any unpaid balances, deductible, copayment, coinsurance, out of network, prior authorization requirements of any type of benefit limitation for the services received. I agree to make payment in full.

In the event that I receive direct payment from my insurance company via check or otherwise, I agree to notify KETALINK of such payment in a timely manner and furnish payment in full.

In the event that I receive direct payment from my insurance company via check or otherwise for services provided by Ketalink, I agree to notify Ketalink of such payment in a timely manner; and endorse such checks (if made out directly to me) to Ketalink or otherwise pay such amounts to Ketalink within 30 days. I understand that failure to do so may result in legal action against me, including a challenge in claims court.

Signature

Emergency Contact Information

Authorization to Disclose Information

Were you referred for treatment by your mental health provider?

Your Mental Health Provider's Information

Select a reason for why you were referred or why you are seeking ketamine treatment.

Indicate the approximate date of when you were first diagnosed

Date

Describe your symptoms. Select all that apply.

These symptoms have affected the following areas of my life:

Please list all of your currently diagnosed psychiatric conditions.

Please list previously tried medications. Be as specific as possible including names, doses, duration or dates of treatment and reason discontinued, in particular regarding at least two tried and failed oral antidepressants.

If not on any medications, put "N/A"

Other interventions/programs/treatments tried:Include approximate dates and response to treatment.

If none, put "N/A"

Have you ever received ketamine treatments in the past?

If you answered 'Yes' to the previous question, which method/route was it given through? Select all that apply

Were you ever hospitalized for psychiatric reasons?

If you answered 'Yes' to the previous question, include approximate dates of hospitalization, reason and where you were hospitalized.

Please list any other past medical or surgical history that you have.

If none, put "N/A"

List all medications that you currently take, including dosage and frequency.

If none, put "N/A"

Have you been diagnosed with any of the following? Select all that apply.

Do you currently use any of the following? Select all that apply.

Gender

What is your approximate height?

What is your approximate weight in pounds?

Do you have any allergies?

If you answered 'Yes' to the previous question, list your allergies here as well as the reaction you get

Are you currently pregnant?

Please list anything else you wish to add or make your provider aware of.

Signature

Date

New Patient Intake Form

Insurance Policy

Medical & Mental Health History