Pregnancy Questionnaire and Waiver

Full Name*

First NameLast Name

Today's Date

Date

Are you currently pregnant or breastfeeding?*

YesNo

Is there a chance you may be pregnant?*

YesNo

Would you like to take a pregnancy test prior to your infusion test today?*

Yes, I would like to take a pregnancy test.No, I have been offered the option of taking a pregnancy test and I decline.

Please Note

Should you fail to inform Vitalitas Denver about a potential pregnancy and/or decline to take a pregnancy test, by your signature below, you agree to waive, release, and discharge any and all liability, claims, demands, actions, or causes of action against Vitalitas Denver or its employees, staff, physicians, and agents from any and all loss, claim, damage, injury, illness, fees or harm as a result of the administration of IV Ketamine Infusion during pregnancy.

Confirmation*

By signing this form I agree and understand that I have an ongoing responsibility to inform Vitalitas Denver staff and physicians if I ever become pregnant or suspect if I may become pregnant.

Signature

Please verify that you are human*