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Consent for Ketamine Treatment - Physician

Welcome to Beyond Mental Health Ketamine Treatment Services! We are proud to operate the only mental health clinic in Hawaii entirely dedicated to the rapid treatment of depression.

At Beyond Mental Health, our mission is to treat mental health conditions more rapidly, more naturally, and with treatments that empower patients to rediscover joy, adopt a purpose, and kindle hope.

It is very important to us that all patients feel welcomed, safe, supported, and respected, and we will address any concerns that might arise in this regard. Beyond Mental Health providers include physicians, psychologists, and therapists. We are governed by certain laws and regulations and by a code of ethics. The ethics code requires that we make you aware of certain office policies that may affect you. Please take time to read this document as it contains important information about our professional services and business policies. It is also highly recommended for all prospective patients to read through the information on our website and the more detailed descriptions of ketamine’s potential and properties as a medication. Please feel free to ask any questions that may arise.

Our clinical methods are informed by the value we place on safety, respect, mutuality, inner- directedness, set and setting, non-judgmental awareness and listening, presence, mindfulness, and the use of non-ordinary states of consciousness in the service of personal healing and transformation. This treatment opens unexpected opportunities for insights that may foster creative problem-solving, personal and relational development and transformation.

Medical History

Psychiatrist:
Therapist / Psychologist:
Primary Care Provider:
Medical Conditions: (i.e. Hypertension, Diabetes, Depression/Anxiety, HIV/Hep C, etc)
Current Medications
Please list your current medications, dosage, and frequency with which you take it.

Allergies?

Any surgical history? (Procedures and Dates)

Females Only - Last menstrual cycle:
Any history of Substance Abuse Treatment?

YES

Any history of Abusing Heroin or Synthetic opioids?

YES

Any history of LSD or Hallucinogen use?

YES

Any history of Methamphetamine use?

YES

Please describe any other use of illicit drugs, or history of using needles:
Please describe any Psychiatric Disorders in the family:

Please describe any Serious Medical Disorders in the family:
(i.e. Heart conditions, sudden cardiac death, stroke, etc.)

Risks:

Ketamine is an FDA-approved medication used for anesthesia; however, it is used off-label for the treatment of mood disorders. Participation in this treatment may result in a number of benefits but there is no guarantee that this will occur.

Side Effects:

With ketamine given intramuscularly there is low risk of abscess, infection, muscle pain and/or soreness at sight of injection.

Common side effects include but are not limited to:

Motion sickness
Nausea
Increased blood pressure and heart rate
Arrhythmias
Anxiety
Dissociation

Less common side effects that may occur:

Increased cardiac output
Increased intracranial pressure
Tachycardia
Tonic-clonic movements
Vivid dreams
Double vision
Injection site soreness
Exacerbation of current liver damage and/or liver disease
Nystagmus (blurred vision)

**Consultation and written approval by a cardiologist is required prior to first ketamine treatment if there is any history of cardiac issues.**

Due to the lack of research of ketamine during pregnancy, receiving treatment while pregnant is not an option. Females of childbearing age are required to take a Urine Pregnancy Test before beginning treatment with ketamine. I acknowledge that ketamine can result in birth defects, fetal death, and/or teratogenicity.

Additionally:

I agree to the following:

I do not have a cerebral aneurysm
I have not had a heart attack or stroke in the past 6 months
I am not taking a MAOI (Monoamine Oxidase Inhibitor) such as: Isocarboxazid, Phenelzine, Selegiline, or Tranylcypromine

I affirm that I have provided a detailed and complete list of all medications and herbal supplements I am taking as some drugs may interact negatively with ketamine.

Examples include:

Antibiotics (ex. Azithromycin, Clarithromycin)
Antifungal agents (ex. Ketoconazole)
Opioids (ex. Hydrocodone, Percocet)
Benzodiazepines (ex. diazepam, alprazolam)
Lamotrigine
Monoamine Oxidase Inhibitors

Treatment Guidelines

I agree to the following guidelines provided below for my pre- and post- ketamine treatment sessions. I understand that failure to abide by these guidelines can result in medical risk, postponement, or cancellation of treatment.

Pre-Ketamine Session

No alcohol 48 hours prior to treatment
No food 8 hours prior to treatment
No coffee, tea, or caffeinated beverages 2 hours prior to treatment
Drink lots of hydrating fluids the day before treatment
** Hydration is necessary for both the IV that will be started prior to treatment, as well as the urine sample for drug screening
All medications taken 72 hours prior to treatment MUST be discussed and cleared with the administering physician
Read Dr. Cook’s “Tip for Success” to arrive to mentally prepared for treatment

Post-Ketamine Session

No alcohol 48 hours after treatment
All medication taken 72 hours after treatment MUST be discussed and cleared with physician
Arrange a ride home; No driving or operating heavy machinery for at least 12 hours after treatment
Relax and rest for the remainder of the day

Fee Schedule

Ketamine treatment is an investment in myself, my relationships, and my life. The fee schedule below is reflective of the combination of education, knowledge, experience, expertise and time that will given to me during the course of my treatment.

Out-of-Pocket Fee

$195 for intial treatment
$395 each treatment thereafter

I understand that the above out-of-pocket fee is for off-label ketamine administration, the ambient dissociative therapy room that my treatment will take place in, as well as the monitoring and management services during my treatment. If I choose to utilize a talktherapist, that service will be billed to my insurance. I understand that if my insurance does not pay the full amount that was billed, I then am responsible for that payment. All payments are due upon arrival.

**I am aware that my physician reserves the right to adjust my fees and that I will be notified at least 2 weeks prior if any changes are being made.**

Monitoring

Video

I am fully aware, and have been informed that, for my physical safety, my ketamine session may be monitored on video camera, and that this is required by the clinic. I fully consent to this recording. I am aware, and have been informed, that my ketamine treatment is neither an urgent, nor an acute care, nor an emergency treatment, but is instead intended to treat a chronically depressed mood and/or other chronic longstanding psychiatric issues, and that all real emergency psychiatric treatments are available at nearby emergency rooms and hospitals. I am aware, and have been informed, that Dr. Tom Cook’s clinic, Beyond Mental Health, is not intended to be an urgent care clinic, but is instead an outpatient clinic open on weekdays, during daylight hours only, and providing an off-label treatment, and I fully consent to this voluntary, elective arrangement. I acknowledge that there is no guarantee that ketamine will help my symptoms.

Optional : Psychedelic Guide

I acknowledge that Beyond Mental Health has explained to me that a supportive psychedelic guide may be offered to sit with me during my treatment, and that this guide has no licensure or official training in psychotherapy, and is there for comfort, consolation, coordination of care, and monitoring purposes only. They are not there to provide any counseling, talk therapy or any other billable clinical services whatsoever. I am fully aware, and have been informed, that if in my case, this clinic is only providing ketamine, but not comprehensive psychiatric care, and that if my primary psychiatrist exists elsewhere, then this clinic in no way replaces my primary psychiatrist, who is still the doctor responsible for my overall care and stability.

Cancellation / No Show Policy:

If I am unable to attend my scheduled appointment on time, I know that unless I call to reschedule 48 hours prior, I will be charged the out-of-pocket fee based off of my treatment selection. I acknowledge that the appointment will be considered cancelled if I arrive more than 15 minutes after my scheduled appointment time. I understand that I will be asked to keep a credit card on file and will be charged for missed appointments without prior notice or approval.

Pregnancy:

I understand that if I am pregnant, if I become pregnant, or if I intend to become pregnant while a patient of Dr. Cook’s Office, I must disclose this information to Dr. Cook’s Office. Failure to do so will result in a termination of this contract and the doctor-patient relationship.

Termination of Treatment:

I acknowledge that I have the right to end treatment at any time without any moral, legal or financial obligation other than those already accrued. I, too, understand that my physician reserves the right to terminate treatment at any time without my consent.

Acknowledgement:

By signing below I am acknowledging that I understand and have read the entirety of this Ketamine Packet, have had my questions answered and concerns addressed to my satisfaction regarding the ketamine services offered. I have reviewed and fully understand the terms and conditions of this agreement. I agree to hold Beyond Mental Health free and harmless from any claims, demands or suits for damages from any injury or complications whatsoever, except for gross negligence or willful misconduct that may result from such treatment.

My signature indicates that I have either received a copy of this agreement in person or by email, or have waived the right to receive a copy at my own insistence.

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July 5, 2022 2:42 pm CST

Consent for Ketamine Treatment - Physician Uploaded by BMH Front Desk - frontdesk@beyond-mh.com IP 66.68.60.75