Spravato Transportation Policy & Driver Information

Spravato® Transportation Policy & Driver Information
Patient Name:
Date of Birth:

MonthDayYear
Date
Treatment Date:

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Date
Transportation Policy & Requirements
To ensure your safety following Spravato® treatment, please review and acknowledge the following:
- I understand that I CAN NOT drive myself home after receiving Spravato treatment.
- I understand that I must arrange reliable transportation before each treatment session.
- I understand that a responsible adult (family member, friend, caregiver, or rideshare driver) must transport me home after treatment.
- I understand that public transportation alone is not recommended.
- I understand that if appropriate transportation has not been arranged, my treatment will be delayed or rescheduled.
- I understand that I can not drive, operate heavy machinery, or engage in activities requiring full alertness for the remainder of the treatment day.
- I understand that I should have a support person available to assist me, if needed, after leaving the office.
Driver Information
Driver's Full Name:
Relationship to Patient:
Phone Number:
Format: (000) 000-0000.
Patient Acknowledgment
I certify that the transportation information provided above is accurate. I understand and agree to follow the transportation requirements for every Spravato treatment. I acknowledge that failure to comply with these requirements may result in my treatment being postponed or canceled for my safety.
Patient/Legal Guardian Signature:
Printed Name:
Date:

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Date

Spravato® Transportation Policy & Driver Information

Transportation Policy & Requirements

Driver Information

Patient Acknowledgment

Driver Acknowledgment