Patient Intake Forms
& Resources

PLEASE COMPLETE OUR PATIENT INTAKE FORMS AND REVIEW OUR POLICIES PRIOR TO BEGINNING KETAMINE INFUSION THERAPY OR IV HYDRATION THERAPY AT OUR CHARLOTTE KETAMINE CLINIC.

Patient Intake Forms

Here you’ll find the series of forms, policies and waivers you need to review and acknowledge prior to receiving ketamine infusions. Please download and/or print and complete these forms, and return them to us at your initial consultation or first scheduled appointment.

Privacy Policy

Please review and agree to our ketamine clinic’s privacy policy.

Acknowledgement of Payment & Cancellation Policy

Please review and agree to our ketamine clinic’s acknowledgment of payment & cancellation policy.

Consent to Electronic Communication

If you would like to receive communication via email and other electronic methods, please read and agree to our policy.

Patient Assessment

Please complete this form and provide us with important information about your medical history prior to beginning ketamine treatments.

Patient Rights & Responsibilities

Please review and agree to our Patient Rights & Responsibilities prior to your first ketamine infusion, IV hydration treatment or other wellness service.

Treatment Consent

Please review our treatment consent form prior to your first visit. We will ask you to sign the document at our ketamine clinic and wellness center.

Physician Referral

Please provide this form to your referring physician and ask them to complete it, and return the form to our ketamine clinic via fax or email.

Waiver of Liability

Please acknowledge the policies of our ketamine clinic and the risk you assume by agreeing to receive ketamine infusions.

Pregnancy Waiver

Please review information about receiving ketamine infusions while pregnant, and acknowledge our policy.