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

Patient Intake Form

For optimal user experience, we recommend completing this form on a computer or tablet. If you have any questions about the patient intake form, our staff is available during regular business hours to assist at (855) 538-9355.

  • Personal Information

  • Verification (such as ID, license, discharge paperwork, etc) will be required.
  • Please mark all that apply
  • Health Information

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  • Personal & Lifestyle

  • If none, type "n/a" or "none"
  • If so, please enter their name below so that they may benefit from our referral program.
  • If so, please list their name/practice below.
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    I confirm that, to the best of my knowledge, this document accurately reflects my personal health information.
  • Medical Records Release & Request


    This form authorizes your health service provider to submit your medical record (or specific portions of it) to Ketamine Wellness Centers.

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    Release from Health Service Provider to Ketamine Wellness Centers

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    I am requesting the provider listed above to release the following information to Ketamine Wellness Centers:

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    Disclosures & Authorization

  • I understand that the information in my health record may include information related to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

  • I understand that I have a right to revoke this authorization, in writing to Ketamine Wellness Centers, at any time. I understand that the revocation will not apply to information that has already been released in response to this authorization.

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    If I fail to specify an expiration date, event, or condition, this authorization will expire in ninety (90) days.
  • I understand that this authorization is voluntary. I can refuse to sign this authorization. I understand that I have a right to inspect and copy the information to be used or disclosed pursuant to this authorization.

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    Signature of patient or legally authorized representative
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