Name *

First Name

Last Name

Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth (DOB) *

MM

DD

YYYY

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Check any of the following that are applicable to you:

Use or history of use of MAOI's / SSRI's / SNRI's.

Heart conditions or serious cardiovascular issues.

Auto-immune disease(s)

Family history of schizophrenia or early onset mental illness.

Seizures / epilepsy malignant hypothermia or other types of susceptibility to heat stroke.

Do you have a support system in place post-session? *

Yes

No

What kind of Ketamine experience are you looking for? *

One-on-one session

Group Ketamine Experience