Ketamine Treatment Consent Form

Permission to Use Ketamine as a Treatment for Depression

Ketamine is a drug that calms and relaxes the body. It is approved by the FDA is for use in adults and for anesthesia and as a pain reliever during medical procedures. It generally does not impact your breathing. Ketamine’s use for treatment of depression or other mental illnesses is off-label and has not been approved by the FDA.

Why Is Ketamine Being Recommended for Me?

Clinical experience shows that ketamine may be used to treat depression in a helpful manner. A number of studies have shown giving ketamine can improve depression. When administered by vein over a period of about 45 minutes (called an infusion), ketamine may help depression improve rather quickly but it may last only a few days. A series of infusions is used so that the improvement last much longer. While the goal is improvement of depression, results cannot be guaranteed.

What Will Be Done?

I will be receiving ketamine by IV Infusion. This means an IV will be inserted into a vein of my hand or elbow and fluid will be dripped into the vein over roughly 45 minutes. This fluid will contain a ketamine at a concentration of 0.5 mg/ kg of my body weight. (By comparison, when ketamine is used for anesthesia the dose is 2 to 9 times higher, and this dose is given over one minute, not 45 minutes). After the treatment I will need a bit of time to recover and may take some sips of fluid if I feel like doing so. I understand that I will be scheduled to receive 6 treatments over about two weeks as a treatment episode. Additional maintenance treatments may or may not be suggested, occurring about once a month or less frequently as recommended by Dr. Fleming based on how I do during the initial 6 sessions and in the time period after that.

What Safety Precautions Must I Take?

  • I may not eat or drink after midnight before each of the infusions.
  • I may NOT drive a car, operate hazardous equipment, or engage in hazardous activities for 24 hours after each treatment as reflexes may be slow or impaired. Another adult will need to drive me home.
  • I must refrain from alcohol or other substances prior to treatment infusions.
  • I must tell the clinic about all medications I am taking, especially narcotic pain relievers or barbiturates.
  • In order to qualify to receive ketamine therapy,I will require medical clearance and must share with my ketamine provider the contact information for the doctor or doctors who are treating my depression or anxiety or other psychiatric symptoms.
  • If I experience a side effect while I am at home, I should contact the doctor who is providing me ketamine (Dr. Fleming at 719-439-7532), my primary care doctor, call 911 or go to my local emergency room.

What Are the Side Effects of Ketamine?

When Ketamine is used as an anesthetic agent the following are listed as side effects:

  • Fast, irregular or low heart beats
  • Increased or decreased blood pressure
  • Dreams that may seem real
  • Confusion
  • Irritation or excitement when waking up
  • Increased saliva or thirst
  • Lack of appetite
  • Headaches
  • Metallic taste
  • Constipation
  • Floating sensation (“out-of-body”)
  • Breathing problems
    Twitching, muscle jerks, and muscle tension
  • Blurry or double vision
  • Nausea or vomiting
  • Risk of drug addiction or dependence

Rare side effects of ketamine are:

  • Allergic reactions
  • Pain at site of injection
  • Increase in pressure inside the eye
  • Ulcerations and inflammation in the bladder
  • Pancreatiti
  • Hallucinations
  • Euphoria
  • Involuntary eye movements
  • Low mood or suicidal thoughts

Side effects of receiving an IV are:

  • Mild discomfort at the site of placement
  • Bruising
  • Bleeding
  • Dizziness
  • Fainting
  • Infection

Important Notices and Agreements:

  • Ketamine Infusion Therapy Is Not A Comprehensive Treatment For Depression, Anxiety Or Any Psychiatric Symptoms
    Your ketamine infusions are meant to augment (add on to, not be used in place of) comprehensive psychiatric treatment. We advise you to be (and I agree to be) under the care of a qualified mental health professional (or an internal medicine or family physician with experience and skill in treating psychiatric illnesses) while receiving ketamine infusions, and for the duration of your psychiatric symptoms. Unless otherwise agreed to, Dr. Fleming will not be the provider of these services. Follow up medications may be suggested but these will be the responsibility of my treating physician.
  • Special Note On Suicidal Ideation
    Psychiatric illnesses (especially, depression) carry the risk of suicidal ideation (thoughts of ending one’s life). Any such thoughts you may have now, at any time during the weeks of your ketamine infusions, or at any point in the future, which cannot immediately be addressed by visiting with a mental health professional should prompt you to seek emergency care at an ER or to call 911.
  • Ketamine Use During Pregnancy Is Not Generally Recommended.

My Consent for Ketamine Treatment is Voluntary:

My request for Dr. Fleming to conduct ketamine infusion treatments as described is entirely voluntary and I have not been offered any inducement to consent. I understand that I may refuse ketamine treatments and that my regular treatments for depression would continue. Any money I have deposited that has not been subject to fees by Neura|gain will be refunded to me if I choose not to proceed. I have been advised that I can seek a second opinion from another doctor before agreeing to have ketamine treatment and am choosing to proceed at this time with or without this second opinion.
Statement of Person Giving Informed Consent(Required)

Statement of Person Giving Informed Consent

Signature of Patient
MM slash DD slash YYYY

Signature of Witness
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The Medical/psychiatric provider treating my symptoms of depression or anxiety or other psychiatric symptoms is :

Release Of Medical Information

I hereby authorize my ketamine provider to disclose my medical records, including any history of substance use or abuse, to the individual listed above, or appropriate personnel in his or her office. I further authorize the individual listed above to disclose my medical records, including any history of substance use or abuse, to my ketamine provider, or appropriate personnel in his or her office.
I also authorize my ketamine provider to discuss my care and share information for the purposed of monitoring, billing, quality control and other business purposes with Natural gain who has agreed to HIPPA levels of security about my personal information.

Signature of Patient
MM slash DD slash YYYY

In The Event Of An Emergency

My Emergency Contact is :

I hereby authorize my ketamine provider to disclose my medical condition to the above person in the event of concern about my post procedure recovery or any emergency situation so that this person may assist me as needed.

Signature of Patient
MM slash DD slash YYYY
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