Ketamine Intake form


Ketamine Intake Form

General Information

Participant: Please write legibly as this information is used to complete your patient chart.

*** Any address, phone or email changes must be submitted in writing to ***

Family Physician and/or Primary Health Care Provider:

Patient Authorization for Delivery of Medications

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.


Patient-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.



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.


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 (, a nonpartisan survey research firm based in Washington, DC


Authorization 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.

The health care provider(s) authorized to release this information are: (please print)

B.I authorize the following health information to be disclosed:


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