Q3Month Self-Evaluation

NutraBrain Refill Program

STOP and read CAREFULLY: Fill this form out ONLY if you have 0 refills left with the pharmacy or if this form has been text messaged or emailed to you by us. Dr. David always gives 3 refills to Subscriber with every prescription. For patients in their first month, this form must be filled out since you have 0 refills. **Please allow up to 2 business days to process your request. 📌 Important: Refills cannot be provided earlier than 30 days from your last pickup date. Lost medication or upcoming travel no longer qualify for early refill exceptions. Thank you for your understanding and cooperation.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Which form of ketamine are you using:
Are you receiving ketamine from any other provider, physician, telehealth company or clinic? Please note, under our terms of service, you cannot use more than one provider for at home ketamine.
On a daily basis, are you using more than what you have been presribed?
How has Ketamine benefited you? Please check all that apply.
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. Have you checked you BMP and LFT in the last 12 months?
How often do you use Ketamine?
Consent: You hereby authorize Dr. David Mahjoubi, 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, 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. Mahjoubi 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, or to reduce alchohol/marijuana usage. Outcomes vary by individual, and not all patients will benefit. You understand that Dr. Mahjoubi 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 regulations You must submit this form every 3 refills, and be seen once a year. 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, and PMP, the national controlled substance database for prescriptions, 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 NutraBrain. 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. David Mahjoubi and NutraBrain 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.
On a scale of 0-100, please rate the extent to which Ketamine has helped you, with 100 being the most help, and 0 being not at all.
Do you feel you are addicted to Ketamine?
Please list all medications that you are taking, including dosages. This includes prescriptions as well as over the counter medications. If there have been no changes since your last Rx Renewal with us, you may write "No changes." If you are not on any prescription medicatoins, please write "None."
Do you use any of the following:
If the answer is Yes to any of the above, please write how often:
Which pharmacy do you prefer we send your prescription to? If no preference, please leave blank. Please note a change in pharmacy does not mean an early refill is possible.
Do you have any new medical diagnosis since your last Rx renewal or in person evaluation:
Have you had surgery since your last Rx renewal or in person evaluation:
Are you experiencing any side effects that you believe are due to at home Ketamine therapy? If you do not please write "No."
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.
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NutraBrain Refill Program