About this template
The Ketamine Therapy Consent Form is an essential document used by medical clinics and psychiatric practices to inform patients about the procedure and secure formal, documented consent. This comprehensive form gathers patient contact information, relevant medical and psychiatric history, and clear acknowledgments of potential risks, side effects, and treatment expectations.
Ensuring that patients fully understand the nature of ketamine-assisted therapy is both an ethical and clinical priority. This template guides patients through treatment details while capturing their formal agreement before any session begins. Clinics can instantly deploy this template via Doc2Form to streamline patient intake, maintain clear treatment records, and ensure every required acknowledgment is captured prior to care.
Key features
- Capture complete patient contact and emergency details securely.
- Document patient acknowledgment of treatment risks and benefits.
- Collect relevant medical and psychiatric history efficiently.
- Secure formal electronic consent prior to administering care.
- Organize patient submissions automatically in Google Sheets.
Use cases
- Ketamine infusion clinics onboarding new patients.
- Psychiatric practices offering psychedelic-assisted psychotherapy.
- Clinical research trials studying novel mental health treatments.
- Specialized wellness centers providing intravenous therapy.
What this form collects
- Patient Full Name (Short answer)Enter your first and last name as it appears on your government-issued ID.
- Date of Birth (Date)Provide your date of birth (MM/DD/YYYY).
- Phone Number (Short answer)Enter the best phone number to reach you or your emergency contact.
- Email Address (Short answer)We will send your appointment confirmations and pre-treatment instructions here.
- Emergency Contact Name and Phone (Paragraph)Provide the name and phone number of someone who can be reached during your treatment appointment.
- Medical History Overview (Paragraph)List any current medical conditions, recent surgeries, or major health concerns.
- Current Medications (Paragraph)List all prescription medications, over-the-counter drugs, and supplements you are currently taking.
- Acknowledgment of Risks and Side Effects (Multiple choice)Ketamine therapy can cause temporary side effects such as dissociation, dizziness, elevated blood pressure, and nausea. Do you acknowledge these risks?
- Transportation Agreement (Multiple choice)Due to the sedative effects of ketamine, patients must arrange for a responsible adult to drive them home after treatment. Do you agree to this requirement?
- Right to Withdraw Consent (Multiple choice)I understand that my participation in ketamine therapy is entirely voluntary and that I may withdraw my consent at any time prior to treatment administration.
- Patient Signature / Electronic Confirmation (Short answer)Please type your full legal name here to serve as your electronic signature confirming your informed consent.
FAQ
What is the purpose of a ketamine therapy consent form?
It ensures patients are fully informed about the risks, benefits, and expected outcomes of ketamine-assisted therapy, while formally documenting their voluntary agreement to proceed.
Can I customize the risks and disclosures listed on this form?
Yes. Once you convert this template to Google Forms, you can easily edit the text to match your clinic's specific protocols, dosing guidelines, and liability disclosures.
How does Doc2Form help me set up this form?
Doc2Form instantly transforms this template structure into a ready-to-use Google Form in your account, saving you time on manual formatting and question entry.
Is patient data secure when using Google Forms for medical intake?
Google Forms offers robust security controls, but clinics should ensure their overall Google Workspace setup meets their specific organizational compliance and privacy requirements.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.