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-KET-WELL.

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-KET-WELL.
  • Personal Information

  • MM slash DD slash YYYY
  • Please mark all that apply
  • Health Information

  • If none, type "n/a" or "none"
  • If none, type "n/a" or "none"
  • If none, type "n/a" or "none"
  • If none, type "n/a" or "none"
  • If none, type "n/a" or "none"
  • If none, type "n/a" or "none"
  • If none, type "n/a" or "none"
  • If none, type "n/a" or "none"
  • If none, type "n/a" or "none"
  • If none, type "n/a" or "none"
  • If none, type "n/a" or "none"
  • If none, type "n/a" or "none"
  • If none, type "n/a" or "none"
  • 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.
  • I confirm that, to the best of my knowledge, this document accurately reflects my personal health information.

Ketamine Wellness Centers

Ketamine Wellness Center’s mission is to provide personalized, compassionate, high-quality care for people suffering from afflictions where Ketamine infusions have proven a successful treatment option (Depression, Chronic Pain, PTSD, OCD, Suicidality) while actively researching Ketamine’s efficacy to treat additional conditions. There is hope. There is help.

PHONE:
855-KET-WELL (1-855-538-9355)

FAX:
844-KET-WELL (1-844-538-9355)

EMAIL:
info@ketaminewellnesscenters.com

CLINIC LOCATIONS:

Chicago, Illinois
603 E Diehl Rd, Suite #139 Naperville, IL 60563

Dallas-Fort Worth, Texas
6144 Precinct Line Road, Suite 100 Hurst, TX 76054

Denver, Colorado
7261 S Broadway, Suite 10-L Littleton, CO 80122

Houston, Texas
12807 Haynes Rd. Building A, Unit 1 Houston, TX 77066

Jacksonville, Florida
3753-2 Cardinal Point Drive Jacksonville, FL 32257

Las Vegas, Nevada
7375 S. Pecos Rd. Suite 102 Las Vegas, NV 89120

Minneapolis-St Paul, Minnesota
11995 County Road 11, Suite 220 Burnsville, MN 55337

Mesa-Gilbert, Arizona
2451 E. Baseline Rd, Suite 300 Gilbert, AZ 85234

Phoenix, Arizona
3724 N 3rd. St. Suite 201 Phoenix, AZ 85012

Reno, Nevada
1895 Plumas St. #6 Reno, NV 89509

Salt Lake City, Utah
6087 S. Redwood Road STE. B Taylorsville, UT

Seattle, Washington
34709 9th Ave S. Suite-B 200 Federal Way, WA 98003

Tucson, Arizona
3130 N Swan Rd. Tucson, AZ 85712