Delic Announces Pending Acquisition of KWC by Peter/PetraMD - Patients Please Contact Us For More Information

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

Other Forms

Insurance Verification Form

Required for patients seeking insurance coverage.

Medical Records Release & Request

Allows KWC to request medical records on your behalf.

Insurance Waiver

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.

Referral Programs

For Patients

For Providers