At-Home Ketamine Prescription Agreement Contract
Please review and acknowledge the treatment terms before signing.
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This agreement outlines the expectations and responsibilities associated with receiving at-home ketamine treatment through Ketamine Healing Clinic of Los Angeles. The purpose of this agreement is to ensure safe use of a controlled medication and to maintain compliance with federal and state regulatory requirements.Ketamine is classified as a controlled substance and must be used exactly as prescribed.
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I agree
1. Use of Medication: I agree to use ketamine only as prescribed by the medical providers at Ketamine Healing Clinic of Los Angeles. I will not alter the dose, frequency, or route of administration without approval from the clinic. I understand that misuse of ketamine can lead to discontinuation of treatment.
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I agree
2. Single Prescribing Provider: I agree that ketamine will only be prescribed to me by Ketamine Healing Clinic of Los Angeles. I will not obtain ketamine from another physician, clinic, telehealth service, or other source while receiving treatment through this clinic.If it is discovered that ketamine has been obtained from another provider without disclosure, I understand that I may be discharged from the practice without refund.
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3. Early Refill Policy: Ketamine prescriptions cannot be refilled earlier than 30 days from the last dispense date. Early refills will not be issued for the following reasons, but not limited to: : • Changes in medication dosage. • Lost medication• Stolen medication• Spilled medication• Travel reasons. Additionally, one month's prescription will be granted at a time.
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I agree
4. Pharmacy Monitoring: I understand that the dispensing pharmacy may notify the clinic if my medication usage appears inconsistent with the prescribed dosing instructions.If pharmacy reports indicate potential misuse, the clinic may:• Issue a warning• Modify the treatment plan• Discontinue at-home ketamine treatment• Discharge me from the practice
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I agree
5. Medication SafetyI agree to store ketamine securely and keep it out of reach of others.I will not share, sell, or give my medication to any other person. Sharing a controlled substance is illegal and may result in discharge from the practice.
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I agree
6. Medication Interactions: I agree to follow the medication guidelines provided by the clinic and to disclose all medications and substances I am currently using.Ketamine should not be combined with medications or substances that may increase safety risks without physician approval.These may include but are not limited to: Benzodiazepines • Alcohol• Sedative medications• Other psychoactive substances. I will inform the clinic of any medication changes.
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I agree
7. Monitoring and Follow-Up: I understand that periodic medical evaluations are required to continue receiving ketamine prescriptions.Failure to attend required follow-up appointments may result in discontinuation of at-home ketamine treatment.
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I agree
8. Clinic Discretion: The medical team reserves the right to discontinue at-home ketamine treatment at any time if it is determined that continued prescribing is not medically appropriate or safe.Patients may still be eligible for in-clinic ketamine infusions at the discretion of the medical team.
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I agree
9. Acknowledgment: By signing below, I acknowledge that I have read and understand the expectations outlined in this agreement. I agree to comply with these requirements while receiving at-home ketamine treatment through Ketamine Healing Clinic of Los Angeles.
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I agree
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