Product: Intranasal Ketamine Therapy
Definition of Telehealth
Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical images and data for the purpose of improving patient care.
Expected Benefits
- Improved access to medical care by enabling a patient to remain in their home.
- More efficient medical evaluation and management.
Possible Risks
- Technical: Delays in evaluation due to equipment failure; breach of privacy via electronic systems.
- Clinical: In rare cases, the lack of a physical exam may prevent the provider from identifying a condition.
- Ketamine-Specific: You understand that Ketamine may cause temporary dissociation, increased heart rate, or nausea. You agree to use this medication only in a safe, controlled environment.
Patient Acknowledgments
By signing this form, I understand and agree to the following:
- Voluntary Nature: I understand that I may withdraw my consent at any time without affecting my right to future care or treatment.
- No Guarantee: I understand that while Ketamine has shown high efficacy for many, no results can be guaranteed.
- Emergency Protocol: I understand that Ketabrain is not an emergency service. In a crisis, I will call 911 or 988.
Identity Verification: I will provide a valid government-issued ID to verify my identity before my first consultation.
