Self evaluation form: Ketamine Healing Refill Program

Self evaluation form: Ketamine Healing Refill Program - CA Residents ONLY

Note: This is only for patients that have been to the clinic in the last 6 months OR have completed all three video consultations with the PA or the doctor and had your last video visit within the last 6 months.
Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
RDT or TrocheNasal SprayNasal Spray with oxytocin
YesNo
YesNo
Decreased depressionDecreased anxietyDecreased painIncrease in energyIncrease in motivation, mental focus and or clarity
Consent for At-Home Prescription of Ketamine: You hereby authorize Dr. Riley, MD to prescribe nasal or oral ketamine for at-home use to you or the individual for whom you are the legal guardian. You acknowledge that the risks of ketamine therapy have been explained to you in person, and you have had the opportunity to ask any questions. You consent to treatment based on this understanding: Ketamine carries both common and rare risks, including but not limited to: Increased urination, urinary changes, or potential bladder/kidney injury (rare and typically seen with usage over 5000 mg/week), headache, constipation, nausea, vomiting sinusitis or discomfort, allergic reactions Insomnia, fatigue, nightmares, dysphoria, or anxiety. Potential triggering or worsening of psychotic disorders. Ketamine can make someone with epilepsy have a seizure- please inform us if you have had a seizure in the past. Memory lapses or dissociation (“blackouts”) during or after use Potential for dependency, craving, or addiction. Please inform Dr. Riley if you: Have a history of seizures, psychotic episodes, or substance abuse Have recently stopped using alcohol or benzodiazepines Are or may be pregnant, trying to become pregnant, or breastfeeding Have experienced fainting, significant cognitive changes, or bladder issues (such as incontinence or abdominal pain) Use of ketamine via nasal or oral routes may cause prolonged drowsiness. You must: Not drive or operate machinery for at least 4 hours after each dose, or 24 hours if you have exceeded your prescribed amount Avoid signing legal or financial documents within 12 hours of taking ketamine Cease all activities if you feel dizzy and sit or lie down immediately You acknowledge that ketamine therapy is not a guaranteed cure for depression, anxiety, PTSD, or chronic pain. Outcomes vary by individual, and not all patients will benefit. You understand that: Dr. Riley is an Anesthesiologist, not a psychiatrist or psychologist You should maintain regular care with a mental health or pain specialist If suicidal ideation arises, you will immediately go to the nearest emergency room or call/text 988, the national suicide hotline You are responsible for seeking help from your primary care physician or specialists as needed In compliance with DEA and Medical Board of California regulations:You must submit this form or be seen in person every 3 refills or at the time of refill expiration. Refills will not be granted before 30 days from your last pickup. Urine toxicology screens may be required; we reserve the right to deny refills for any reason. The clinic monitors CURES, the California Department of Justice database, to verify that patients are not receiving ketamine from multiple providers. Use of multiple providers for ketamine therapy will result in permanent termination of your prescription relationship with the Ketamine Healing Clinic. You acknowledge that compounded ketamine is not FDA-approved for psychiatric disorders, and its use is off-label. Ketamine may cause reproductive harm; you release Dr. Riley and Ketamine Healing Clinic of Los Angeles, Inc. from liability for any birth defects or related issues. The clinic does not issue or sign disability-related paperwork. These requests must be directed to your diagnosing physician. By signing this form, you confirm a diagnosis of depression, anxiety, PTSD (by a certified mental health expert), or chronic pain (by a physician), Affirm you have fully disclosed your medical history, including psychiatric and substance use history, Accept all risks outlined above and agree to follow the terms and safety precautions. You understand there is no guarantee of benefit and that all care is delivered under the bounds of regulatory and clinical standards. Should your symptoms worsen or fail to improve, you are advised to contact your appropriate medical provider or emergency services.it is highly recommended by the Ketamine Healing Clinic that you check a BMP, basic metabolic profile, and LFT, liver function tests including AST and ALT, at least once a year to make sure your bladder, kidneys and liver are not affected by Ketamine. This is done via blood draw and can be ordered by your primary care physician, or online at Lapcorp.com.*
NoYes
Please list ALL medications you take including over the counter, without writing the dosages. If there is no change since the last time you filled out this form, please write "no change since last time." *
NoneMarijuanaCocaine or amphetamines or heroinAlcohol more than three times per weekOther illegal drugs not listed
Please list any new medical diagnosis or surgeries since your last evaluation online or in person. Write "none" if none. *
Are you experiencing any side effects you believe may be due to ketamine? If none write "no."
I understand that using more than one doctor or company to receive prescriptions for Ketamine will result in permanent termination of my prescription through the Ketamine Healing Clinic of Los Angeles, Inc.. I am aware that my prescribing activity will be checked on the California CURES database (or relevant state equivalent- PMP) to verify I am not receiving ketamine from multiple providers. If multiple prescribers are identified, I understand my prescription may be immediately discontinued.I am aware that prolonged Ketamine use may cause damage to the lining of the bladder and bladder dysfunction. Long term studies on the prolonged use of Ketamine have not been done. I affirm that all responses provided in this form are accurate and complete to the best of my knowledge. I understand that providing false or incomplete information may result in denial of treatment, reporting to regulatory agencies, or discontinuation of care. I understand that my personal and medical information provided on this form is protected under HIPAA and will be used only for the purpose of clinical evaluation and prescription decision-making. I understand that the clinic may request a urine toxicology screen to assess for compliance or potential substance misuse, and that a refusal may result in denial of further treatment or prescriptions. I understand that if I experience a mental health crisis, suicidal ideation, or adverse physical or psychological effects from ketamine, I will immediately discontinue use and contact 911 or report to the nearest emergency room. By signing this form, I confirm that I have read and understood all risks, requirements, and responsibilities related to at-home ketamine therapy. I consent to receive a prescription under these terms and agree to comply with all safety instructions and medical follow-up requirements as described above.*

My Products*

Rx Refill

Please select this option ONLY if you have received a telehealth visit or in person infusion in the last **6 months**. Completing this form gives you 3 refills pending an evaluation of your answers and nationwide controlled substance check.

$200.00 Quantity

Total

$0.00

Payment Details
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Self evaluation form: Ketamine Healing Refill Program - CA Residents ONLY