Ketamine Intake form Ketamine Intake FormGeneral InformationParticipant: Please write legibly as this information is used to complete your patient chart.First NameMiddle NameLast NamePreferred PronounsDate of Birth(MM/DD/YY):Height:Weight: Marital Status: Single Married Divorced Widowed Gender: Male Female Please list your preferred pronounsNumber of Children:Current Home Address: CityStateZip CodePhone NumberEmail: Emergency Contact Info:Phone:Is your emergency contact aware they are listed as your emergency contact Yes NoHow did you hear about us? Did a medical professional refer you?I authorize contact from this office to confirm my appointments, treatments, and billing information by means: Cell Phone Home Phone Text message Email All of the above*** Any address, phone or email changes must be submitted in writing to info@optimal-medicine.com ***Family Physician and/or Primary Health Care Provider:Doctor/Other:Phone: AddressCityStateZip CodeMay we send a copy of your consultation to your physician or primary health care provider and consult with them as necessary? Yes NoWhat is your highest level of education?Medical History: Check all that apply. Glaucoma High blood pressure Heart arrythmia Chest pain or angina Heart Attack Stroke Deep vein thrombosis/blood clots Migraines Atrial fibrillation Pacemaker Asthma or COPD Diabetes Hypoglycemia Liver or kidney problems Urinary tract problems Gastrointestinal problems Hepatitis Head injuries Epilepsy or seizure disorder Sleep apnea Cancer None of the abovePlease describe any additional medical conditions not listed above. Please include dates and current treatments for the above checked boxes:Are you pregnant or breastfeeding? Yes NoPlease list any surgeries or hospitalizations including dates:Have you had any major accidents? If so, please describe and provide dates.Please list any prescription medication you are currently taking include name dose and reason for use.Please list any dietary supplements, vitamins, micro dosing. Include name, dose, and reason for use:Some of the following questions are very personal and can potentially bring up painful emotions or memories. If it feels too much to answer these questions, please make note below and we can discuss it during our medical intake.Psychiatric History: Please check all you have been diagnosed with or suspect you suffer from? ADHD Depression Anxiety PTSD (Post Traumatic Stress Disorder) Complex PTSD Substance use disharmony or addiction. Suicide attempts Suicidal ideations Obsessive compulsive disorder Multiple personality disorder Borderline personality disorder Schizophrenia or other psychosis Dissociative identity disorder Bipolar disorder Seasonal depression Narcolepsy None of abovePlease describe any additional psychiatric conditions not listed above, include dates and current treatments for the above checked boxes:Do you currently have a counselor or therapist? If so, who? How often do you see them? Are they supportive of Ketamine Therapy:Have you ever been physically, emotionally, or sexually abused as a child or an adult? If inclined to share, please do.Have you experienced any traumatic losses as a child or adult? Please share:Are there any other childhood, adolescent, or adult life experiences that you care to share?How do you typically cope with difficulty or adversity in your life?How often do you struggle managing your anger? Rarely Sometimes OftenHow often do you experience stress? Rarely Sometimes OftenAre you actively being treated for substance use disharmony? Yes NoDo you smoke cannabis or drink alcohol? If so, please describe frequency, and how much in a day/week/month?Are you willing to abstain from stimulants, cannabis, and alcohol for 48 hours prior to your session? Yes NoWhat previous experience have you had with psychedelic medicine? Please describe recreational, guided, ceremonial or therapeutic? Please include any difficult or challenging experiences.Have you or your parents or siblings ever been hospitalized for Schizophrenia or a psychotic break? Yes NoAre you happy with your weight? Yes NoHow many meals do you eat per dayWhen was the last time you drank alcohol? Please list what type and how muchAre you concerned about your alcoholic intake? Yes NoCommentsIn the last year have you drank alcohol or used drugs more than you meant to? Yes NoPlease list any non-prescription drugs/medications you are currently taking:As a result of drinking or drug use has anything happened in the last year that you wished hadn’t happened. Please give a brief description:Are you happy with your sex life? Yes NoDescribe the current stressors in your life:Please check boxes that apply to current or history of suicidality. Check all that apply Self Mother Father Sibilings Significant Other Not applicablePlease check boxes that apply to alcohol abuse. Check all that apply Self Mother Father Sibilings Significant Other Not applicablePlease check boxes that apply to drug abuse. Check all that apply Self Mother Father Sibilings Significant Other Not applicablePlease add any other pertinent health information below:Please list any drug allergies?Please check boxes that apply to current or history of psychosis or schizophrenia. Check all that apply Self Mother Father Sibilings Significant Other Not ApplicablePatient Authorization for Delivery of Medications I, (print name and DOB) hereby authorize the clinic’sstaff on duty to act on my behalf to accept medication delivery from the clinic’s dispensing physician and deliver my medications and refills to me as prescribed by my physician. I understand that delivery of such medications can be picked up at the clinic or mailed to my provided address on a weekly basis (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing. Any orders delivered damaged or incomplete must be reported to Optimal Medicine; referred to as OAM within 24 hours of delivery and the pictures of the damaged package/product must be sent to info@optimal-medicine.com. OAM is not financially responsible or liable for lost or stolen items once delivered. Once items have been scanned and delivered to the customer's address, it is up to the customer to report any missing or stolen packages to OAM within 24 hours of the delivery date. Any packages returned for an INCOMPLETE/ INCORRECT address can be shipped again at the patient's expense.No Guarantee of Services We do not guarantee that any services or medications will be provided to you until you have undergone the full initial sign up process and physician’s examination. At the physician’s discretion only, you will be provided medications and/or services during your program at Optimal Medicine. OAM requires you to have an annual consultation with our provider and annual lab work done. Lab work every 6 months is preferred but not required. Additional lab work can be requested by the provider at any time. No Refund Policy *Optimal Medicine reserves the right to have NO RETURN and NO REFUND policy.Today’s DateFINANCIAL POLICY Payment is due at the time of treatment. We accept several methods of payment including cash, check, major credit/debit cards. If a balance has exceeded $200.00 or existed over 90 days, your privilege to schedule appointments will be suspended until the account is current. In the event of unforeseen circumstances, please communicate with our office to arrange and sign a payment plan. If you have questions on your recommended treatment plan or the available payment options, please do not hesitate to ask. We are here to help you! Missed Appointment Policy: Your appointment time is reserved for you; please arrive on time to maximize your time with the doctor. Please give 24-hour notice if you are unable to keep your appointment, or a $50 fee may be applied to your account. General (non-insurance): Fees are to be paid at time of service. Charges will be based on the treatment you receive, which may include a consultation, labs, and other supportive care. Private Insurance: Optimal Medicine currently does not bill insurance I have read and understand the office policies and fees of this office. I understand that I am ultimately responsible for payment of my care and any fees incurred.Date / TimePatient-Physician Contract We are now in a new era of Health Care Reform - intended to help patients. Sadly, these reforms do not include any “Lawsuit Reforms” that would dramatically reduce costs for patients and also promote a better environment for patients and their physicians. In a recent nationwide poll* 83% of the nation’s electorate wanted Congress to address the medical malpractice system as part of the Health Care Reform plan. We wish Congress had taken action implementing reforms that both doctors and patients could support. And the majority of patients agree. Congress missed the opportunity. Because of that we have taken action with the single goal of enhancing the relationship between patients and the physician. We take great pride in our reputation for providing the highest levels of quality medical care to our patients. However, we realize there are times when some patients will not be satisfied with the outcomes of their treatments. We also recognize that in these instances, a patient has every right to pursue legal action if he/she feels we have been negligent in some way. We respect every patient’s right to do so. While some healthcare legal claims are justified, there are also frivolous legal claims filed in our country—claims that are driving up insurance rates and impacting court decisions for the patients who truly deserve compensation. We believe that an agreement early in the treatment process regarding the use of properly credentialed experts will help expedite resolution of concerns. OUR COMMITMENT TO YOU We commit to using only properly credentialed expert medical witness(es) in any legal situation, who follow the code of ethics of our national specialty society. These steps ensure that expert medical witnesses we use have passed examinations, demonstrated expertise in their field and adhere to a solid code of ethics. We demonstrate this commitment to you with our signature on this form. WHAT WE ARE ASKING YOU TO DO We are asking you or any representative to commit to this process also, by using only properly credentialed physician(s) as expert medical witness(es) if you are dissatisfied with your medical care and decide on legal action. We hope, and believe, you will never have to consider this again. But if you do, we will honor this commitment to you. * Poll conducted by Clarus Research Group (www.ClarusRG.com), a nonpartisan survey research firm based in Washington, DCAGREEMENT AS TO RESOLUTION OF CONCERNS “I”, “Patient/Guardian” shall be understood to mean (Please print) “Physician” shall be understood to mean Leah Sullivan FNP-BC and Optimal Medicine. Further, I understand that I am entering into a contractual relationship with a Physician for professional care. I further understand that meritless and frivolous claims for medical malpractice have an adverse effect upon the cost and availability of medical care and may result in irreparable harm to a medical provider. As additional consideration for professional care provided to me by Physician, I, the patient/guardian and/or my representative agree not to advance, directly or indirectly, any false, meritless, and/or frivolous claim(s) of medical malpractice against Physician. Furthermore, should a meritorious medical malpractice case or cause of action be initiated or pursued, I (the patient) and/or my representative agree to use properly credentialed expert medical witness (es) by the same specialty board as Physician. Furthermore, I agree that these expert witnesses will be members in good standing of and adhere to the guidelines and / or code of conduct defined for expert witnesses by the AANP. Finally, you (the patient) agree that counsel for me (Physician) shall have the right and be free to depose such expert witnesses at least 120 days before any scheduled trial date. In further consideration for this, I, (the Physician), agree to the same stipulations. Patient/Guardian and Physician acknowledge that monetary damages may not provide an adequate remedy for breach of this Agreement. Such breach may result in irreparable harm to Physician’s reputation and business. Patient/Guardian and Physician agree in the event of a breach to allow specific performance and /or injunctive relief. Leah Sullivan FNP, BC ProviderPatient/Guardian (please print)Treatment Start DateAuthorization for Release of Medical Records*This document MUST be signed by the patient in order to receive copies of their complete medical records including but not limited to test results and treatment plan for themselves. I(please print), DOB: authorize the following health care provider(s) to release specified protected health information to Optimal Medicine at the following address:753 SW 11th St. Ste A, Redmond, OR 97756.The health care provider(s) authorized to release this information are: (please print)Provider NameOffice phone #: Office fax #: B.I authorize the following health information to be disclosed: My complete medical records and information: including but not limited to, test results, as well as information related to HIV status, drug and alcohol usage, and mental health status (but this authorization does not include the release of psychotherapy notes). My medical records only for the specific treatment dates fromTO The following described portions of my medical records and private health information: C. I authorize this health information to be used and/or disclosed for the purpose of assisting the health care provider, Optimal Medicine, provide treatment to me. D. I authorize (spouse/caretaker/partner/other) to receive my protected health care information and/or call on my behalf for the reasons listed, but not limited to, below: My complete medical records and information: Test results, Appointments and scheduling, Physical exam notes, treatment plan Requesting medication and/or lab test orders. This Authorization expires: On the following date:Date / Time OR When the following event occurs: F. I understand the following with respect to this Authorization: a). I have the right to revoke this Authorization at any time by providing the disclosing health care provider(s) with a written request specifically stating my desire to revoke this Authorization. The disclosing health care provider(s) must accept this revocation and may not refuse to continue to provide me with health care treatment. If I revoke this Authorization, it is effective except to the extent that any disclosing health care provider has already used or disclosed my protected health information in reliance on this Authorization. b.) If someone other than me has initiated the request for the use and/or disclosure of the information described above, I may inspect or copy the information to be used and/or disclosed and then revoke this Authorization. G. A faxed copy and/or a photocopy of this Authorization shall be as valid as the original signed copy. *This document MUST be signed by the patient in order to receive copies of their complete medical records including but not limited to test results and treatment plan for themselves.Date SignedSubmit