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.

Complete the Form

Cancellation Policy

Please review our cancellation policy and acknowledge your understanding and agreement.

Complete the Form

Privacy Policy

Please review and agree to our privacy policy, outlining how we may use your personal information.

Complete the Form

Consent to Electronic Communication

Please agree to receive communication electronically from Ascend Ketamine.

Complete the Form

Treatment Consent

Please review the terms and conditions for receiving ketamine infusions at Ascend Ketamine.

Review the Terms

Ascend Ketamine | Payment

Ketamine Treatment Downpayment

Please pay for your ketamine infusion prior to your appointment.

Pay Now

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.

Download & Print