Mandatory NutraBrain New Patient Intake Form

Please select which state you live in. **Note, answering "None of the above" disqualifies you from receiving service from us.

Have you received an at-home ketamine prescription from another Doctor, provider, or telehealth company in the last 30 days? Please note you can only use 1 provider, and we have access to a national database for all ketamine prescriptions.

In the past 2 weeks, have you had thoughts of suicide?

Are you located in Los Angeles or Orange County, CA? Please note we do not serve LA and OC County at this time.

Are you currently pregnant, breastfeeding, or trying to become pregnant?

Have you ever been diagnosed with bipolar disorder AND currently experiencing an episode of mania (e.g., days of decreased need for sleep with elevated energy, racing thoughts, impulsive behavior)

Have you (or a first-degree relative) ever been diagnosed with schizophrenia or had a psychotic episode?

What condition are you seeking treatment for:

If any of the following apply to you, please stop what you are doing and do not proceed:

NutraBrain conducts a monthly state wide as well as interstate check of all controlled substances prescribed to each individual receiving a prescription for Ketamine. You understand that using more than one doctor, or company/online service, to receive Ketamine will result in cancellation of your prescription.

By signing this document, you attest that you have been diagnosed with depression, anxiety, or PTSD by a certified mental health expert using appropriate diagnostic criteria, and that you have disclosed to us any history of: Substance abuse, Psychotic disorders or episodes, Seizures or seizure-related conditions. Important Safety Guidelines- Driving and Operating Machinery: Ketamine can cause drowsiness and cognitive changes. You must not drive within 2 hours of using Ketamine at home if taken as prescribed. If you have taken more than prescribed, you must avoid driving or operating heavy machinery for 24 hours. Pregnancy Warning: Ketamine may cause birth defects. It is your responsibility to inform the clinic if you are pregnant, may be pregnant, or are attempting to become pregnant. Mental State and Decision-Making: You should not sign important documents or make major decisions within 24 hours of using Ketamine. Addiction/Misuse: Please stop using Ketamine and notify Dr. Mahjoubi immediately if you find yourself craving Ketamine, feel addicted, or experience adverse effects such as increased forgetfulness, fainting, or other changes in health or cognition. Emergency Protocol: If you are having thoughts of suicide or experiencing a mental health crisis, please go to the nearest Emergency Room or call 911 immediately. If you continue to feel unwell despite ketamine therapy, contact your psychiatrist, psychologist, or mental health expert. Scope of Care: If you are being treated with Ketamine for chronic pain and experience a flare-up, please contact your pain management physician. Off-Label Use and FDA Statement: Ketamine is FDA-approved as an anesthetic. However, its use for mood disorders like depression, anxiety, and PTSD is considered off-label. This means it is not FDA-approved for these specific psychiatric indications, though off-label use is a common and legal practice in medicine when supported by clinical experience and emerging evidence. The compounded form of ketamine prescribed may not be FDA-approved for any psychiatric or mood-related use, as indicated by official FDA guidance. Treatment Discontinuation: Dr. Mahjoubi reserves the right to discontinue treatment at any time if there are concerns about safety, misuse, non-compliance, or clinical appropriateness. This is essential to ensure responsible medical care. Prescription Monitoring: The clinic utilizes the CURES and PMP (Prescription Monitoring Programs) to monitor ketamine prescribing and confirm that patients are not receiving similar prescriptions from multiple providers. Please note the FDA alert and official position on compounded Ketamine: "Compounded Ketamine is not approved for any psychiatric disorder or mood treatment. Please note NutraBrain's policy on cancelling, rescheduling, or missing your telehealth appointment: Missing your appointment will result in a $150 fee to rebook. Telehealth Acknowledgment & Legal Notice: I understand that my evaluation and treatment with Dr. David Mahjoubi, MD, and NutraBrain will be conducted via telehealth, which uses secure audio/video technology.• I consent to receive medical services through telehealth voluntarily and may withdraw consent at any time.• I agree to disclose my current physical location at the start of each telehealth session.• I understand that telehealth has limitations compared with in-person evaluation and that emergencies require calling 911 or going to the nearest emergency department.• My telehealth visits will not be recorded without my written consent.• I understand my telehealth services comply with HIPAA privacy and security standards, but electronic transmission may pose residual privacy risks.• I have the right to access my medical information and records in accordance with my states law.• Any dispute arising from my telehealth treatment shall be governed by my states laws and resolved exclusively via arbitration. You understand that Dr. Mahjoubi does not recommend taking more than 300 mg as a one time dose, or in a 24 hr period, outside direct and in person medical supervision by a doctor or nurse. You understand that Dr. Mahjoubi recommends that you have a trusted and competent adult with you when taking 200 to 300 mg at a time, or in a 24 hour period. If you are unable to calculate dosages, Ketamine must not be taken at home or outside a medical setting.

If you have a history of high blood pressure, stroke, or heart attack, you must inform Dr. Mahjoubi 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. Mahjoubi and a pulse oximeter must be used when using ketamine. "Ketamine bladder" has been reported in the literature- Dr. Mahjoubi 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. Mahjoubi 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.

Address

Please upload a copy of your drivers license so we may confirm your identity. A passport or state ID will suffice if you do not have a drivers license.

How did you hear about us?

I agree to receive communicatoins in the form of emails and text messages from NutraBrain Clinic, Inc. and Dr. David Mahjoubi, MD.

Name

First NameLast Name

Phone Number

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

Birth Date

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NutraBrain Home Prescription