At Home Ketamine Prescription Program - Video Visits

At Home Ketamine Prescription Program - Video Visits - For California residents ONLY

This is for telehealth visits for at home ketamine only. Please note, you must reside in the state of CA and be in CA at the time of your video visit. If you have any questions prior to submitting this form, call or text 424-278-4241, or email support@phos.la
Are you a resident of California? If not, please stop and do not submit this form.
I declare I will physically be in California during the time of my video visit.
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Ketamine Informed Consent & Safety Agreement

CARDIOVASCULAR & RESPIRATORY MONITORING

If you have a history of hypertension, stroke, or heart attack, you must inform Dr. Riley at your consultation and use a blood pressure monitoring device during ketamine use.If you have a history of COPD or emphysema, you must inform Dr. Riley and use a pulse oximeter during ketamine use.

SAFETY RULES DURING USEOnly use ketamine while sitting in a safe, secure area in your home.Never use ketamine in or near a bathtub, swimming pool, or jacuzzi — and do not enter any of these after using ketamine. Doing so can result in death.Do not take ketamine with alcohol, other prescription drugs, or any other substances. Doing so can result in loss of life.Do not exceed your prescribed daily dose.

BLADDER & KIDNEY HEALTH:

"Ketamine bladder" has been reported in the medical literature, though Dr. Riley has never had a patient develop this condition. Risk is associated with a pre-existing history of bladder or kidney dysfunction, or use of quantities well beyond the prescribed maximum. Stop using ketamine and contact us immediately if you experience incontinence or lower abdominal pain.

ADDICTION RISKKetamine has been prescribed to you on a trial basis. There is a small risk of addiction, which occurs almost exclusively in patients with a personal or family history of drug or alcohol abuse. If signs of developing addiction appear, your doctor may discontinue the prescription.

POSSIBLE SIDE EFFECTS:

Legal regulations require disclosure of all possible side effects, however rare. These include: increased urination, headache, constipation, nausea, vomiting, discomfort, change or loss of taste, change or loss of smell, sinusitis, and allergic reaction. Bladder or kidney injury is possible only with significant overuse — amounts far exceeding the maximum of 1,400 mg per week.

Ketamine may worsen a pre-existing psychotic disorder. Please disclose any history of psychosis or substance abuse to Dr. Riley.

Ketamine may trigger seizures in people with a seizure disorder, and in those who have recently stopped drinking alcohol or taking benzodiazepines. Please inform Dr. Riley of any seizure history or recent cessation of these substances.

If you are unfamiliar with any of the monitoring devices or symptoms mentioned above, please contact our office — we are happy to help.
By signing below, I confirm that I have read, understood, and agree to the conditions outlined above. I acknowledge the risks associated with ketamine use and agree to follow all safety guidelines as described.
Please upload a copy of your drivers license or state ID for California. We cannot send Ketamine to any other states.

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1st Video Consultation

This option is for new patients beginning at-home ketamine therapy. If you are eligible, your first month’s prescription will be filled by the compounding pharmacy. Please note that payment for the medication is made directly to the pharmacy.

$250.00 Quantity

2nd Video Consultation

When you are ready for your second month's prescription

$225.00 Quantity

3rd Video Consultation (select follow up if you've already completed 3 visits)

When you are ready for your third month’s prescription, you will receive that refill along with two additional refills (a total 3-month supply). The compounding pharmacy will dispense this one month at a time. Please note that early refills are not granted.

$200.00 Quantity

Follow up Video Visit

You must be seen by us every 6 months for a continued prescription.Choose this ONLY after you've completed all 3 video visits OR a series of infusions at our clinic.

$250.00 Quantity

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At Home Ketamine Prescription Program - Video Visits - For California residents ONLY

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