Patient Intake Forms
The evaluation process to become a patient at Ketamine Wellness Centers is as follows:
- Complete the Patient Intake form
- Read & sign the Ketamine Information Package
- Complete the Depression Index
Once these forms are complete, a Patient Liaison will contact you to schedule the screening.
Required Intake Forms
I. Patient Intake Form
II. Ketamine Information Package
III. Depression Inventory Assessment
Insurance Verification Form
Required for patients seeking insurance coverage.
Medical Records Release & Request
Allows KWC to request medical records on your behalf.
Required for patients who are not using insurance to pay for treatment.
Authorization for Communication
Required if patient wants someone else to communicate with KWC on their behalf.