Medical Records Release & Request Form

If you have any questions about this form, our staff is available during regular business hours (Mon – Fri, 9am – 6pm) to assist. Call us at 855-KET-WELL.

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

Patient Information:

Patient's Name(Required)
MM slash DD slash YYYY
Address(Required)

Release from Health Service Provider to Ketamine Wellness Centers

Provider Address

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

The specific information to be used or disclosed is as follows:(Required)
(e.g. further care, insurance claim, attorney inquiry, at the request of the individual, personal use, etc.)

Select your Ketamine Wellness Centers Clinic:

Phone: 855.KET.WELL | Fax: 844.KETWELL

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.

MM slash DD slash YYYY
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.

MM slash DD slash YYYY
Name of Legal Representative or Guardian if the Patient is a minor.

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