The Ketamine Therapy Consent Form collects a patient name and contact details, followed by choices about reviewing provider information, awareness of side effects, voluntary consent, and whether questions were answered. A final optional field allows further questions or concerns. The seven-question sequence asks about prior explanations from the healthcare provider; it does not supply treatment risks, alternatives, or instructions. Negative and clarification answers can finish the form, including a refusal of treatment. Everyone reaches an ending that asks them to discuss unresolved matters with their provider and states that completion does not authorize or schedule treatment.
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Separate information-review and side-effect questions help intake staff see which parts of the provider conversation may need revisiting.
The question about whether concerns were answered provides a patient-reported discussion status before a treatment decision.
The name, contact field, and optional concerns provide context for a care-team review of consent or refusal.
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