Spravato® (esketamine) is an FDA-approved medication administered in-office under thesupervision of a certified healthcare provider as part of the Risk Evaluation and MitigationStrategy (REMS) program. It is used in combination with an oral antidepressant for treatment-resistant depression or major depressive disorder with suicidal thoughts or behaviors.

• Spravato is administered only in this office.
• You must remain in the office for a minimum of 2 hours after each dose.
• You will be monitored for blood pressure changes, sedation, dissociation, and other sideeffects.
• You may not leave early without medical clearance.

Before each treatment:

• Blood pressure will be checked.
• You must report any changes in medications or medical conditions.
• You must report pregnancy or breastfeeding status.During monitoring

During monitorning:

• You may experience dizziness, nausea, sedation, or dissociation.
• Staff will monitor you until medically cleared for discharge.

• Treatments are scheduled in advance due to medication ordering and monitoring requirements.
• A minimum of 24-48 hours' notice is required for cancellation.
• Late cancellations or no-shows will result in fees.
• Repeated missed visits may result in discontinuation of treatment.

Failure to comply with these requirements may result in discontinuation of treatment.

• You are responsible for verifying insurance coverage.
• Copays, deductibles, or coinsurance are due at time of service.

• Authorization does not guarantee payment.
• You are responsible for any claims denied.

Treatment may be discontinued if:

• Safety concerns arise
• Noncompliance with monitoring or transportation policies
• Repeated missed appointments
• Clinical determination by provider

I acknowledge that I have read and understand the Spravato treatment policies outlined above. I agree to comply with all safety, monitoring, transportation, and financial policies required for treatment.