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    Form - Patient History

In order to expedite the sign-in process and get you to treatment faster, patients arriving for Ketamine treatments are asked to complete this form before your visit to our clinic. You may also download the form and This email address is being protected from spambots. You need JavaScript enabled to view it. it to us.

Note: If you have a physician or therapist who referred you to us, please ask him or her to complete this referral form.

Please let us know your name.
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Please let us know your email address.
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Patient Attestation: By submitting this form, I certify that I have completed this Patient Form to the best of my ability. I agree to seek immediate help should my symptoms worsen or I experience an increase in suicidal thoughts, feelings or urges. I authorize a representative from the Vitality Medical Infusions to contact me to discuss treatment options for my condition(s). I also understand that the staff of Vitality Medical Infusions will not start and maintain any prescribed treatment regimen if I am not currently under the care of a Mental Health Professional and maintain such care until the completion of my course of treatment.
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