Ketamine IV Informational Call Scheduling Form

Ketamine IV Informational Call Scheduling Form

Please complete this form only if you are interseted in Ketamine IV Therapy
Please select a time for your informational call and complete the information below. The information allows us to be prepared for the call. We will call you at the number provided. *
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell phone number*
Please enter a valid phone number.
What is your date of birth? *

MonthDayYear
Date
What is your sex?*

FemaleMale
How did you hear about us?*

A friend or family member recommended IHM!Facebook/InstagramTV CommercialGoogle SearchOther
Do you have a current primary care provider?*

YesNo
Who is your primary care provider?
Briefly, what are the main concerns you are hoping to improve with Ketamine IV Therapy?*
Please list any mental health related diagnoses you have received from a licensed medical practitioner and the month and year you were diagnosed.
Are you seeing a licensed mental health professional for therapy/counseling?*

YesNoI used to see a therapy/counselor, but am not currently.
When was the last time you saw your therapist/counselor? *
Please list all your current prescription medications. (You do not need to list vitamins and supplements). *
Do you have medical insurance?*

YesNo
What is the name of your primary insurance company?*

MedicareBlue Cross Blue ShieldAetnaUnited HealthcareHumanaCignaOther
What is your member or subscriber ID listed on your insurance card?
What is the group number listed on your insurance card?
What is the Medicare number listed on your Medicare card?
Do you have a supplemental policy? (A policy that often picks up what Medicare doesn't pay?)

YesNo
What is the name of your supplemental policy?
What is the member or subscriber number on your supplemental insurance card?
Which type of insurance policy do you have?*

PPOHMO (HMO policies are not accepted, but we have Cash Patient Options)EPOOther
Integrative Health Matters is a functional medicine clinic. IHM Providers accept some patients for Ketamine IV Therapy. A provider consult is required for clearnace before any Ketamine IV therapy is approved.

While the initial provider consult may be billed to and covered by your insurance, Ketamine IV Therapy is not a billable service and is not covered by insurance. We will discuss the cost for Ketamine IV therapy during the informational call.

By completing and signing this form, you are simply signing up for an informational call to learn about the Ketamine IV program at Integarive Health Matters. There is no cost for this informational call.

After the informational call, you may be offered to scehdule a clinical consult with an IHM medical provider. This clincal consult with a medical provider is required before any Ketamine IV therapy is scheduled.

By signing below, I agree that I have answered all questions truthfully to the best of my ability.
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