You hereby authorize Dr. David Mahjoubi, MD to prescribe you, or the person for whom you are the legal guardian, intra-nasal, sublingual, or oral Ketamine. You have been explained the risks of Ketamine, and any other medications Dr. Mahjoubi has informed you he will prescribe, and have had a chance to ask questions- you wish to receive prescription strength Ketamine for at home use only. Ketamine carries risks including but not limited to: headache, constipation, nausea, vomiting, discomfort, change or loss of taste sensation, change or loss of smell sensation, sinusitis, changes in urination or possible bladder or kidney injury, and allergic reactions. Prescription strength medications, while considered safe, carry the risk of heart irregularities, heart attack, stroke, seizure, brain damage or death. Rarely, nausea and/or vomiting may persist for weeks or months. Loss of weight, nightmares, and abnormal sweating associated with the sensation of heat for a month or more can happen after receiving Ketamine. Ketamine may also worsen a psychotic disorder if one is present- please let the doctor know if you have a history of substance abuse or psychotic disorders. Rarely, Ketamine can trigger a seizure. Please let the doctor know if you have a history of seizures, have stopped drinking alcohol or taking benzodiazepines, or think you may have had a seizure in the past.
By signing this document, you attest to have been diagnosed with depression, anxiety, or PTSD by a certified mental health expert (or pain by a physician) who uses appropriate diagnostic criteria, that you have disclosed any history of substance abuse, and that you have disclosed any history of psychotic disorders or episodes.
Important Prescription Policy Update: In order to ensure continued compliance with the DEA and Medical Board of CA regarding at-home Ketamine therapy, effective July 1, 2021, the following required documentation will be needed by the Ketamine Healing Clinic of L.A. to continue providing prescription refills:
Medical records from a psychologist or psychiatrist with your diagnosis. A record of past psychotropic medication use from a pharmacy will suffice. If you are using Ketamine for pain, records from your prior treating physician (e.g. surgeon or pain management physician) will suffice. A “clearance letter” from the physician who has diagnosed you may be used in lieu of medical records. Kindly remit the requested documentation via fax: 747-877-3019 or email: RX@ketaminehealing.com.
We reserve the right to cancel any prescription refill pending the results of a urine toxicology screen, or for any other reason. Ketamine via the nasal or oral route can cause prolonged drowsiness, therefore, you must not drive within two hours of using Ketamine at home, assuming you have used the Ketamine according to the instructions on the prescription. If you have used more than which is prescribed you must wait 4 hours or longer before driving or operating machinery.
You release Dr. David Mahjoubi and the Ketamine Healing Clinic of Los Angeles, Inc., of all liability in the event of a vehicular accident or bodily or psychological injury or harm. Ketamine at home in oral or spray form may cause birth defects to your fetus, it is your responsibility to inform Dr. Mahjoubi and the office if you are or may be pregnant, or if you are trying to get pregnant. By signing this form, you release Dr. David Mahjoubi, MD, and Ketamine Healing Clinic of Los Angeles, Inc. of all liability related to birth defects or reproductive harm to you or your fetus. There is no guarantee for relief of depression, PTSD, anxiety, or chronic pain.
Dr. Farzad D. Mahjoubi is an Anesthesiologist, not a Psychiatrist or Psychologist- if you wish to see one please inform him so that he can refer you to one. Rarely, insomnia, fatigue, dysphoria, stress, or anxiety may occur with intra-nasal or oral Ketamine. Additionally, some individuals “black out” or do not remember anything. Please lessen your usage if you find that you are faint, cannot remember as well as before, or experience any other side effects following use. Please stop usage if you find you are craving Ketamine, or think you are addicted to Ketamine, and let Dr. Mahjoubi know as soon as possible. It is important that you do not sign important documents within 12 hours of each dose of intranasal or oral
Ketamine you self-administer. Please exercise caution and do not take more than that which is prescribed to you. If you are feeling dizzy, you must sit or lay down, and stop what you are doing. While intranasal or oral Ketamine does benefit many people, every individual responds differently, and not everyone will gain immediate or long- term relief from Depression, Chronic Pain, or any other mood irregularity.
Due to DEA and California Medical board guidelines, as well Dr. Mahjoubi’s practice guidelines, the Ketamine Healing Clinic of Los Angeles asks that you be re- evaluated by Dr Mahjoubi in person or via phone every 3-4 months of using intranasal or oral ketamine. In some instances Dr. Mahjoubi may ask to evaluate you sooner. Such re-evaluation may include submitting a urine and/or blood toxicology screen. Dr. Mahjoubi reserves the right to discontinue intranasal or oral Ketamine therapy if he deems such therapy to be ineffective, addictive, or for any other reason. Because Ketamine is a controlled substance, early refills are not possible with nasal or oral Ketamine. There are no exceptions to this rule.
If you feel your daily Ketamine requirements are more than that which is prescribed, please email Dr. Mahjoubi to discuss this. Always seek the help of your primary care provider if you are feeling unwell or sick. If you have made plans to commit suicide, please go to the closest Emergency Room before using Ketamine.
The Ketamine Healing Clinic of Los Angeles does not diagnose any condition- thus we are unable to fill out or sign any documents for disability benefits on your behalf. Such requests should be made to the treating physician that provided you with the initial diagnosis.
Your agreement to the terms and conditions signifies that all questions have been answered to your satisfaction, that you fully understand the risks involved with nasal or oral Ketamine, and you agree to all aforementioned statements contained in this document. You understand that no warranty or guarantee of a result or cure has been made.
Should you feel depressed despite ketamine therapy whether in IV oral or nasal form, please contact your mental health expert such as a licensed psychiatrist or psychologist. If you have a pain flare up and are receiving ketamine for pain, contact your pain management doctor. If you do not have a provider, contact your primary care physician, or go to the nearest emergency room, or text/call 988 the national suicide hotline.
