At Home Ketamine Prescription Program - Video Visits

Yes

Name*

First NameLast Name

Phone Number*

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

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Date of Birth *

Date

If any of the following apply to you, please stop completion of this form and do not proceed. *

Informed Consent and Controlled Substance Treatment Agreement for At-Home Ketamine Therapy (California)Ketamine Healing ClinicTelehealth & In-Person ServicesThis document is an informed consent, controlled substance agreement, and treatment contract (the “Consent and Agreement”) between the undersigned patient (“Patient”) and the treating physician and/or Ketamine Healing Clinic (“Clinic”), a California medical practice. This agreement is intended to comply with applicable California medical practice laws, telehealth regulations, and federal and state controlled-substance requirements, including DEA and California CURES (PDMP) obligations.Please read this document carefully. By signing, you acknowledge that you understand and voluntarily agree to all terms below.1. Purpose of TreatmentKetamine is a Schedule III controlled substance approved by the FDA as an anesthetic and prescribed off-label at lower doses for certain mental health conditions, including but not limited to treatment-resistant depression, anxiety disorders, and PTSD. You are being prescribed ketamine for at-home administration as part of a structured treatment plan overseen by a California-licensed physician.Forms of ketamine that may be prescribed include: - Intranasal ketamine (nasal spray) - Oral ketamine troches (lozenges) - Rapidly dissolving tablets (RDTs)Off-label prescribing is a common and legally permissible medical practice. You acknowledge that ketamine use for mental health conditions is off-label.2. Telehealth-Specific Consent (California)You consent to receiving ketamine treatment services via telehealth, which may include video visits, phone visits, electronic messaging, and remote clinical monitoring, in accordance with California law.You understand and agree that: - Telehealth has limitations compared to in-person care. - Accurate assessment depends on your truthful reporting of symptoms, medication use, and side effects. - Technical failures or privacy risks may occur despite reasonable safeguards. - You must be physically located in California at the time of telehealth visits.You agree to notify the Clinic immediately if you experience severe side effects, medical emergencies, or psychiatric destabilization.3. Nature of At-Home Ketamine TherapyAt-home ketamine therapy involves self-administration of a controlled substance without direct in-person supervision. You acknowledge that this increases risk and therefore requires strict adherence to dosing, timing, and safety instructions.You understand that the Clinic relies on your compliance, honesty, and ability to follow instructions to provide this treatment safely. We reserve the right at Ketamine Healing Clinic to cancel your prescription for reasons related to, but not limited to: using more than prescribed, combining with other illicit substances or controlled substances, suspicion of addition to any substance. There are strict criteria to qualify for at home ketamine. These criteria include: 1. No signs of acute distress 2. No ongoing ongoing substance abuse 3. No history of history of sciozophrenia or psychosis, including history of involuntary hospitalization for mental health reasons including section 5150. This is not an all inclusive list. We reserve the right to disqualify you from our program. If we conclude you do not meet these criteria after your first video visit, no refunds are issued, no exceptions. If you miss your appointment, no refunds will be issued. 4. Potential BenefitsPotential benefits may include, but are not guaranteed to include: - Reduction in depressive symptoms or suicidal ideation - Improvement in mood, emotional regulation, or psychological flexibility - Reduction in anxiety or trauma-related symptoms - Enhanced response to psychotherapyNo outcome is guaranteed.5. Risks and Side EffectsCommon or Expected Side EffectsDissociation or perceptual changesSedation, dizziness, or impaired coordinationNausea or vomitingHeadacheIncreased heart rate or blood pressurePsychological RisksAnxiety, panic, or distressConfusion or disorientationWorsening depression, anxiety, or PTSD symptomsInduction of mania or psychosis, particularly in vulnerable individualsSerious and Life-Threatening RisksRespiratory depressionCardiac complicationsLoss of consciousnessAccidental injury while impairedDependence, misuse, or addictionOverdose, which may result in permanent injury or deathYou explicitly acknowledge that using ketamine outside of the prescribed dose, frequency, or route of administration can result in serious harm or death.6. At-Home Safety RequirementsYou agree that you will: - Use ketamine only exactly as prescribed. - Not drive, operate machinery, or make important decisions on dosing days. - Avoid alcohol, opioids, benzodiazepines, stimulants, or other sedating substances unless expressly approved by your physician. Do not go into a bath tub, swimming pool, jacuzzi, stream room or sauna after taking ketamine. Do not drive or operate heavy machinery after taking ketamine. Have a safe, private environment during dosing sessions. - Store ketamine securely in compliance with California controlled-substance storage expectations. - Never share, sell, divert, or transfer ketamine to any other person. 7. Controlled Substance Agreement (DEA & California PDMP / CURES)You acknowledge and agree that: - Ketamine is a Schedule III controlled substance regulated by the U.S. Drug Enforcement Administration (DEA) and the State of California. - The prescribing physician will review the California Controlled Substance Utilization Review and Evaluation System (CURES) and other monitoring tools as required by law. - The Clinic may limit, modify, or discontinue prescribing based on safety concerns, PDMP findings, or regulatory requirements.You agree to: - Disclose all current medications, substances, and prescribers. - Use a single prescribing clinic and pharmacy for ketamine unless otherwise approved. - Submit to reasonable monitoring, which may include questionnaires, pill counts, or other compliance measures.8. Contractual Agreement to Use Only as PrescribedYou acknowledge that this document constitutes a binding treatment contract between you and your physician.By signing, you agree that: - You will not alter dosing, frequency, timing, or route of administration. - You will not take extra doses, combine doses, save doses, or use ketamine outside scheduled treatment sessions. - Any deviation from prescribed use is dangerous and may result in serious injury or death.9. Non-Compliance and Discharge from CareYou understand and agree that: - Any violation of this Consent and Agreement—including misuse, overuse, diversion, dishonesty, or failure to follow safety requirements—will result in immediate discharge from the Clinic. - Discharge may occur without tapering and without further ketamine prescriptions. - Discharge decisions are made to protect patient safety and comply with medical and legal obligations.10. No Early Refills PolicyYou understand and agree that: - There are no early refills for ketamine for any reason, including lost medication, travel, increased symptoms, dosing errors, or perceived lack of efficacy. - Requests for early refills will be considered a violation of this agreement.11. Alternative TreatmentsAlternatives to ketamine therapy include but are not limited to: - Psychiatric medications - Psychotherapy (e.g., CBT, EMDR, trauma-focused therapies) - Transcranial magnetic stimulation (TMS) - Electroconvulsive therapy (ECT) - Lifestyle and behavioral interventions - Declining treatmentYou understand you may pursue any alternative or no treatment at all.12. Voluntary Participation and Termination of CareYou understand that participation is voluntary. You may withdraw from treatment at any time. The Clinic may also terminate treatment if it is deemed unsafe, inappropriate, or non-compliant with this agreement or applicable law.13. Acknowledgment, Authorization, and ConsentBy signing below, you acknowledge that: - You have read and understood this entire document. - All questions have been answered to your satisfaction. - You understand the risks, benefits, and alternatives. - You understand that misuse of ketamine can result in serious injury or death. - You voluntarily consent to at-home ketamine therapy under California law and the terms of this agreement.***For requests to changes in your current prescription you must have a video consultation as ketamine is a controlled substance regulated by the DEA*** *

If you have a history of hypertension, stroke, or heart attack, you must inform Dr Riley during your consultation and use a blood pressue monitoring device during Ketamine use. If you have a history of COPD or Emphysema, you must inform Dr. Riely and a pulse oximeter must be used when using ketamine. "Ketamine bladder" has been reported in the literature- Dr. Riley has never had a patient with this condition, and this could occur if a person has a pre-existing history of bladder or kidney dysfunction, or is using excessively high quantities well beyond our daily maximum. You agree to stop using Ketamine if you become incontinent or have pain in your lower abdomen (please note Dr. Riley has never had a patient develop this condition). If you are unfamiliar with these types of medical monitoring modalities or symptoms, please ask us. 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 my prescription. Taking ketamine with other prescription drugs, alcohol, or substances may result in loss of life. Taking Ketamine in a bath tub, swimming pool, 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.RARELY, there are side effects &/or risks associated with ketamine use. Legal regulations mandate that we list all POSSIBLE side effects, however rare. Ketamine carries the risk of increased urination, headache, constipation, nausea, vomiting, discomfort, change or loss of taste sensation, allergic reaction, change or loss of smell sensation, sinusitis, or possible bladder or kidney injury with significant overuse (this would require much greater quantities then our maximum of 1400 mg per week). Ketamine may worsen a psychotic disorder if one is present- please let the doctor know if you have a history of substance abuse or psychotic disorders. In people with a seizure disorder, Ketamine may trigger a seizure. Please let the doctor know if you have a history of seizures, have stopped drinking alcohol or taking benzodiazepines abruptly.*

Please upload a copy of your drivers license or state ID for California or Virginia. We cannot send Ketamine to any other states. *

My Products*

1st Video Consultation

$250.00 Quantity

2nd Video Consultation

$225.00 Quantity

3rd Video Consultation

$200.00 Quantity

Follow up Video Visit

You must be seen by us every 6 months for a continued prescription.Choose this ONLY after you've completed all 3 video visits OR a series of infusions at our clinic.

$250.00 Quantity

Prescription changes

Any changes to your ketamine dosage require a formal video consultation as ketamine is a controlled substance. Please select this if you would like to discuss changes to your at home ketamine dosage or route of administration

$200.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

At Home Ketamine Prescription Program - Video Visits - For California residents ONLY