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Ketamine Infusion Inquiry Form[email protected]2023-03-02T13:35:44-04:00

Ketamine Infusion Inquiry

Ketamine Treatment Information:

Although each patient will have an individual plan, the standard induction phase consists of six infusions in a three-week period. Treatment sessions are approximately one hour long and will be administered on Tuesday’s and Thursday’s from 8am-3pm. We are not currently offering services outside of these days.

Ketamine Infusions are not covered by insurance.

"*" indicates required fields

Which Location?*

Name

First Last

Date Of Birth:

MM slash DD slash YYYY

Phone:

Email:

Address

Street Address City State ZIP Code

Do you have Insurance?

Yes

No

Primary Insurance:

Primary Insurance ID:*

Do you have Secondary Insurance?

Yes

No

Secondary Insurance:

Secondary Insurance ID:*

Do you currently have any of the following providers?

A Primary Care Doctor?

Yes

No

A Psychiatrist?

Yes

No

A Therapist?

Yes

No

Primary Care Doctor (Full Name):

Doctor Phone Number:

Current Psychiatrist (Full Name):

Psychiatrist Phone Number:

Therapist (Full Name):

Therapist Phone Number:

Do you have a history of substance abuse (Alcohol, cannabis, non-prescribed medications, etc.)*

Yes

No

Question Answer: Do you have a history of substance abuse (Alcohol, cannabis, non-prescribed medications, etc.)*

Do you have a history of history of psychosis?*

Yes

No

Question Answer: Do you have a history of history of psychosis?*

Do you have a history of increased intracranial pressure?*

Yes

No

Question Answer: Do you have a history of increased intracranial pressure?*

Are you currently pregnant?*

Yes

No

Do you have a history of uncontrolled hypertension?*

Yes

No

Question Answer: Do you have a history of uncontrolled hypertension?*

Do you have a history of Acute or unstable cardiovascular disease?*

Yes

No

Question Answer: Do you have a history of Acute or unstable cardiovascular disease?*

Have you had any previous negative response to ketamine?*

Yes

No

Question Answer: Have you had any previous negative response to ketamine?*

Are you currently on any medications?*

Yes

No

Please list your current medication:

Current Medications*

Please check the medications below that you've tried in the past:

Drug Choice 1

Celexa (citalopram)

Lexapro (escitalopram)

Third Choice

Luvox (fluvoxamine)

Paxil (paroxetine)

Zoloft (sertraline)

Trintellix (vortioxetine)

Viibryd (vilazodone)

Pristiq (desvenlafaxine)

Cymbalta (duloxetine)

Effexor (venlafaxine)

Drug Choice 1

Fetzima (levomilnacipran)

Savella (milnacipran)

Elavil (amitriptyline)

Anafranil (clomipramine)

Norpramin (desipramine)

Sinequan (doxepin)

Tofranil (imipramine)

Wellbutrin (buroprion)

Remeron (mirtazapine)

Serzone (nefazodone)

Trazodone (desyrel)

Drug Choice 1

Abilify (aripiprazole)

Lithium (eskalith)

Tegretol (carbamazepine)

Equettro (carbamazepine XR)

Lamictal (lamotrigine)

Rexulti (brexpiprazole)

Trileptal (oxacarbazepine)

Latuda (lurasidone)

Please list any other medications not mentioned above:

How did you hear about us?

Internet

Social Media

Psychology Today

Word Of Mouth

Medical Provider/Hospital

Other

Which Medical Provider/Hospital?

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Bishop Medical Group offers outpatient addiction & psychiatric services for clients in Portland, ME and the surrounding areas.

Contact Details

100 Gannett Dr
Suite A
South Portland, ME 04106
(888) 280-2585
[email protected]

Admissions: (888) 280-2585
[email protected]

Portland, Maine

100 Gannett Dr Suite A South Portland, ME 04106
(888) 280-2585
[email protected]

100 Gannett Dr
Suite A
South Portland, ME 04106
Office: (207) 742-8558

Delray Beach, Florida

402 SE 6th Ave, Delray Beach, Fl 33483
(888) 280-2585
[email protected]

402 SE 6th Ave
Delray Beach, Fl 33483
Office: (561) 359-1934

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