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Name *

First Name

Last Name

Phone *

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Attestations *

Please click the check boxes below:

1. I attest that I am physically located in the state of Florida.

2. I consent to treatment with ketamine despite being experimental and off label for treatment resistant anxiety, depression, PTSD and chronic pain.

3. I attest that I am not experiencing uncontrolled hypertension, unstable cardiovascular disease, severe pulmonary diseases, or recent stroke.

4. I attest that I will adhere to all provided guidelines and dosing regimens. I will abstain from food and any sedatives for at least six hours before taking ketamine.

5. I attest that I will have a trusted individual present during treatment for assistance if needed.

6. I understand that this agreement does not obligate Discreet Ketamine to prescribe the medication until or unless the treating physician deems me medically suitable for this treatment.

7. I understand that if I am not a candidate for ketamine treatment, my payment will be refunded with no out of pocket cost.

8. I acknowledge that prescriptions for this treatment will be reported to the Prescription Drug Monitoring Program (PMDP) database. Other healthcare providers with access to this database may be aware of my ketamine prescriptions. I consent to Discreet Ketamine obtaining my prescription records.

9. I agree to abide by all applicable laws and regulations pertaining to the use of the prescribed medication. I agree to follow the rules and guidelines set forth by my physician at Discreet Ketamine and as documented in the consent. Noncompliance will result in discharge from the practice.

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