Patient Portal
Your journey towards wellbeing begins here.Ascend Ketamine | New Patient Intake Forms
Welcome to Ascend Ketamine, and thank you for making us a part of your journey towards wellbeing. Before you begin your exploration of ketamine infusion therapy, please complete and/or review the following documents:
FORMS TO BE COMPLETED ONLINE & REVIEWED:
Medical History Form
Please complete this form, detailing key aspects of your medical history.
Cancellation Policy
Please review our cancellation policy and acknowledge your understanding and agreement.
Privacy Policy
Please review and agree to our privacy policy, outlining how we may use your personal information.
Consent to Electronic Communication
Please agree to receive communication electronically from Ascend Ketamine.
Treatment Consent
Please review the terms and conditions for receiving ketamine infusions at Ascend Ketamine.
Ascend Ketamine | Payment
Ketamine Treatment Downpayment
Please pay for your ketamine infusion prior to your appointment.
Ascend Ketamine | Acknowledgement of Ongoing Care
The Acknowledgement of Ongoing Care form may be printed and provided to your primary care physician or mental health clinician; he or she may email, fax or mail the completed form back to our office.
Acknowledgement of Ongoing Care
Please download and print this form, and provide it to your referring clinician.