If you're interested in receiving Ketamine infusions for a Mental Health or Chronic Pain disorder, the next step will be to download and complete 3 forms......
#1) Medical History form
#2) Medical Information Release form
#3) Permission, Consent, and Disclosure form (please complete the one appropriate for your diagnosis)
Please review the Permission, Consent, and Disclosure form very carefully. If you have any questions, you may bring the form with you for your first infusion and sign it there.
The top portion of the Medical Information Release form needs to be completed with the contact information for a therapist or practitioner who can confirm a Mental Health or Chronic Pain disorder. You do not need a referral from your Provider, but we do need to confirm your diagnosis before you'll be able to schedule your infusions.
Once you've completed the 3 forms, please email them to us at: info@JacksonHoleKetamineClinic.com
Upon receiving the forms, we'll forward your Medical Information Release form to your Provider to confirm your diagnosis, and we'll review your completed Medical History form and let you know if there is any other information or testing that we'll need to have completed.
Please don't hesitate to contact us with any questions you may have before completing the forms. Our email address and phone number are listed at the bottom of the page.
Medical information form
medical history form
Please complete the appropriate permission and consent form for your specific diagnosis. If you have more than one diagnosis please complete just one permission and consent form.