NutraBrain Ketamine Home Therapy

Name*

Phone Number*

Please enter a valid phone number.

Choose the date and time you would like to have your video consultation with the Doctor. Please note, for appointments with the Nurse, you must text or call 949-514-8261 to schedule.

Date of birth: *

Date

Are you physically located in California, Texas, New Mexico, Utah, Connecticut, Virginia, Illinois, New Jersey, Massachusetts, Wisconsin or New York? If not, please stop and do not submit this form as you are not located in one of our licensed states. You must do the video consultation from one of the aforementioned states.*

Email*

example@example.com

What condition are you seeking treatment for:*

If any of the following apply to you, please stop what you are doing and do not proceed: *

The Ketamine Healing Clinic of Los Angeles and Orange County conducts a monthly state wide as well as interstate check of all controlled substances prescribed to each individual receiving a prescription for Ketamine. You understand that using more than one doctor, or company/online service, to receive Ketamine will result in cancellation of your prescription.*

By signing this document, you attest that you have been diagnosed with depression, anxiety, or PTSD by a certified mental health expert using appropriate diagnostic criteria, and that you have disclosed to us any history of: Substance abuse, Psychotic disorders or episodes, Seizures or seizure-related conditions. Important Safety Guidelines- Driving and Operating Machinery: Ketamine can cause drowsiness and cognitive changes. You must not drive within 2 hours of using Ketamine at home if taken as prescribed. If you have taken more than prescribed, you must avoid driving or operating heavy machinery for 24 hours. Pregnancy Warning: Ketamine may cause birth defects. It is your responsibility to inform the clinic if you are pregnant, may be pregnant, or are attempting to become pregnant. Mental State and Decision-Making: You should not sign important documents or make major decisions within 24 hours of using Ketamine. Addiction/Misuse: Please stop using Ketamine and notify Dr. Mahjoubi immediately if you find yourself craving Ketamine, feel addicted, or experience adverse effects such as increased forgetfulness, fainting, or other changes in health or cognition. Emergency Protocol: If you are having thoughts of suicide or experiencing a mental health crisis, please go to the nearest Emergency Room or call 911 immediately. If you continue to feel unwell despite ketamine therapy, contact your psychiatrist, psychologist, or mental health expert. Scope of Care: If you are being treated with Ketamine for chronic pain and experience a flare-up, please contact your pain management physician. Off-Label Use and FDA Statement: Ketamine is FDA-approved as an anesthetic. However, its use for mood disorders like depression, anxiety, and PTSD is considered off-label. This means it is not FDA-approved for these specific psychiatric indications, though off-label use is a common and legal practice in medicine when supported by clinical experience and emerging evidence. The compounded form of ketamine prescribed may not be FDA-approved for any psychiatric or mood-related use, as indicated by official FDA guidance. Treatment Discontinuation: Dr. Mahjoubi reserves the right to discontinue treatment at any time if there are concerns about safety, misuse, non-compliance, or clinical appropriateness. This is essential to ensure responsible medical care. Prescription Monitoring: The clinic utilizes the CURES and PMP (Prescription Monitoring Programs) to monitor ketamine prescribing and confirm that patients are not receiving similar prescriptions from multiple providers. Please note the FDA alert and official position on compounded Ketamine: "Compounded Ketamine is not approved for any psychiatric disorder or mood treatment. Please note our clinic's policy on cancelling, rescheduling, or missing your telehealth appointment: there will be a $100 re-booking fee for cancelling or rescheduling within 24 hours of your appointment time. Missing your appointment will result in a $150 fee to rebook, or forfeiture of the entire payment. Telehealth Acknowledgment & Legal Notice: I understand that my evaluation and treatment with Dr. David Mahjoubi, MD, and the Ketamine Healing Clinic of Los Angeles will be conducted via telehealth, which uses secure audio/video technology.• I consent to receive medical services through telehealth voluntarily and may withdraw consent at any time.• I agree to disclose my current physical location at the start of each telehealth session.• I understand that telehealth has limitations compared with in-person evaluation and that emergencies require calling 911 or going to the nearest emergency department.• My telehealth visits will not be recorded without my written consent.• I understand my telehealth services comply with HIPAA privacy and security standards, but electronic transmission may pose residual privacy risks.• I have the right to access my medical information and records in accordance with my states law.• Any dispute arising from my telehealth treatment shall be governed by my states laws and resolved exclusively via arbitration.*

If you have a history of hypertension, stroke, or heart attack, you must inform Dr. Mahjoubi during your consultation and use a blood pressue monitoring device during Ketamine use. If you have a history of COPD or Emphysema, you must inform Dr. Mahjoubi and a pulse oximeter must be used when using ketamine. "Ketamine bladder" has been reported in the literature- Dr. Mahjoubi has never had a patient with this condition, and this could occur if a person has a pre-existing history of bladder or kidney dysfunction, or is using excessively high quantities well beyond our daily maximum. You agree to stop using Ketamine if you become incontinent or have pain in your lower abdomen (please note Dr. Mahjoubi has never had a patient develop this condition). If you are unfamiliar with these types of medical monitoring modalities or symptoms, please ask us. *

*Ketamine has been prescribed to me on a trial basis. There is a small risk that ketamine addiction can occur. Almost always, this occurs in patients with a personal or family history of other drug or alcohol abuse. If it appears that I may be developing addiction, my doctor may determine to end my prescription. Taking ketamine with other prescription drugs, alcohol, or substances may result in loss of life. Taking Ketamine in a bath tub, swimming pool, or jacuzzi, or going into a bath tub or jacuzzi, after using Ketamine can result in death. Only use Ketamine while sitting in a safe and secure area in your home. Do not use more than that which is prescribed to you on a daily basis. *

I understand the Ketamine Healing Rx program covers the cost of the first prescription ONLY, and to qualify for the refill program, which gives you three refills at a time without needing a video consultation, you must INITIALLY complete three consecutive video consultatoins over three months. *

Address*

Please upload a copy of your drivers license so we may confirm your identity. A passport or state ID will suffice if you do not have a drivers license. *

Patient Instructions for using Ketamine at home. Please download.

You understand that using more than one doctor or company to receive prescriptions for Ketamine will result in cancelation of your prescription without any refund for consultations completed.*

Yes

Please note, Dr. Mahjoubi has never had a paient with bladder injury from Ketamine. That being said, you are aware that prolonged Ketamine use or overuse may cause damage to the lining of the bladder and bladder dysfunction. Long term studies on the prolonged use of Ketamine have not been done. *

You agree to inform your psychologist, therapist, and/or psychiatrist (if you have one) of starting Ketamine therapy. *

RARELY, there are side effects &/or risks associated with ketamine use. Legal regulations mandate that we list all POSSIBLE side effects, however rare. Ketamine carries the risk of increased urination, headache, constipation, nausea, vomiting, discomfort, change or loss of taste sensation, allergic reaction, change or loss of smell sensation, sinusitis, or possible bladder or kidney injury with significant overuse (this would require much greater quantities then our maximum of 1400 mg per week). Ketamine may worsen a psychotic disorder if one is present- please let the doctor know if you have a history of substance abuse or psychotic disorders. In people with a seizure disorder, Ketamine may trigger a seizure. Please let the doctor know if you have a history of seizures, have stopped drinking alcohol or taking benzodiazepines abruptly.*

How did you hear about us? *

My Products*

First Month Protocol (the cost for the Ketamine prescription is covered by us the first month minus shipping costs if you are outside CA). If you have never received Ketamine from us, you must choose this option.

$400.00

Second Month Protocol Only applies if you have completed the first month protocol with us, and must be at least 30 days after your first consultation appointment (no sooner).

$300.00

Third Month Protocol Only applies if you have completed the first two months of the protocol, and must be at least 30 days after your second consultation (no sooner).

$200.00

Prescription Refill (only applies if you have completed all three video consultations). To receive 3 refills

$175.00 Quantity

Total

$0.00

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NutraBrain Home Prescription Protocol