Ketamine Therapy Consent Form

Ketamine Therapy Consent Form
Patient Information
Full Name
First NameLast Name
Email
example@example.com
Phone Number
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Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Gender
FemaleMaleOther
Informed Consent
I, hereby, understand the following risks and statements;
The risks include the following common side effects: nausea/vomiting, dysphoria (unpleasant visions or feelings), short-term elevations in blood pressure and heart rate, increased saliva production, dizziness, blurred vision and changes in motor skills. These common side effects of ketamine are short-lived after the infusion is stopped and the medicines will be available to treat many of these symptoms if necessary. You will undergo a recovery period after the infusion before you leave the clinic. It is possible that ketamine will interact with other medications you may be taking. You must disclose all medications you are taking as well as any substances including alcohol, illegal drugs and legal drugs.
I agree the risks and statements above.
Current Date
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Date
Patient's Signature
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Witness' Full Name
First NameLast Name
Witness' Signature
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Provider's Full Name
First NameLast Name
Provider's Signature
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Patient Information