Online Payment Options

Deposit Form + Other Payment Options

Welcome to Ketamine Healing Clinic! We’re excited to support you on your healing journey. To secure your FIRST appointment, please select the $200 deposit option below. This ensures your spot is reserved and allows us to prepare for your personalized care. We look forward to seeing you soon. — Dr. David Mahjoubi & The Ketamine Healing Team
Patient Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth *

MonthDayYear
Date
I authorize the Ketamine Healing Clinic of Los Angeles, Inc. and DBA Orange County to charge the credit or debit card indicated the amount I have chosen. I certify that I am an authorized user of this credit card, and that I will not dispute the payment with my credit card company so long as the transaction corresponds to the terms indicated in this form and the consent form. I understand there is a 48 hour cancellation policy requiring me to inform the Ketamine Healing Clinic that I cannot keep an appointment. In case of no shows or cancellation within 24 hours, the deposit is forfeited.
Signature*

Powered by Jotform SignClear

My Products*

New patient deposit

$200.00 Quantity

Pay full Amount for the 2nd, 3rd, 4th, or 5th Infusion with the Doctor, Shannon, or Brandon.This includes the initial in-person consultation.

$700.00 Quantity

Pay Full Amount for a Booster Infusion with the Doctor, Shannon, or Brandon. ONLY applicable if you have completed 5 IV infusions at our clinics, or can show proof of 5 infusions at another clinic.

$500.00 Quantity

Remaining Balance for 1st infusion visit with the Doctor, Shannon, or Brandon. Applies only if you have paid a $200 deposit.

$500.00 Quantity

Pay Full Amount for an Infusion with Nurse Shannon in Los Angeles ONLY (does not apply to Costa Mesa)This includes a video consultation with the Doctor prior to your first appointment.

$395.00 Quantity

Remaining balance for 1st Infusion with Nurse Shannon - Los Angeles Clinic ONLY Only applies if you have paid the $200 deposit.

$195.00 Quantity

Tier 1 Pain Infusion or 2 hour Mood Infusion.

$800.00 Quantity

Tier 2 Pain Infusion - 3 hours

$1,100.00 Quantity

Tier 3 Pain Infusion - 4 hours

$1,600.00 Quantity

6 Infusion Membership LA CLINIC ONLY - Only for existing patients who have completed 5 infusions with us (or transfers from other clinics who can show proof of 5 infusions completed).By signing this form, you are paying for 6 infusions that do not expire and can be used at the LA clinic. This contract is non transferable. Should you decide to request a refund before completing 6 infusions, you can according to the following terms: each infusion received will be reassessed at $495 per infusion. Any late cancellations or no shows will result in loss of 1/2 session from your membership.

$2,600.00 Quantity

90 minute Ketamine Infusion Applies only if you have had 5 infusion at the Ketamine Healing clinic.

$600.00 Quantity

Veteran's Discount for Initial Series Infusions with Dr. David Mahjoubi or the Costa Mesa Clinic (infusions #1-5)Must show proof that you are a Veteran

$600.00 Quantity

Ketamine Booster Shot for TMS

$30.00 Quantity

Remainder Balance for Tier 3 Pain Infusion

$1,400.00 Quantity

Remainder Balance for Tier 2 Pain Infusion

$900.00 Quantity

Remainder Balance for Tier 1 Pain Infusion

$600.00 Quantity

Remaining Balance for Booster Infusion with the Doctor, or Shannon or Brandon in Costa Mesa

$300.00 Quantity

Cancellation Fee

$200.00 Quantity

Enter coupon

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Consent for IV Ketamine InfusionsKetamine Healing Clinic of Los Angeles, Inc.Ketamine Healing Clinic of Orange County, Inc.Thank you for choosing our clinic. Please read this form carefully. We are committed to your safety and well-being. 1. Treatment Overview You consent to receive IV Ketamine infusions administered by Dr. David Mahjoubi, MD or a certified registered nurse anesthetist. Ketamine is used off-label to treat depression, anxiety, PTSD, and chronic pain. It may take several sessions to see results, and some patients may not benefit. 2. Medication Interactions & PrecautionsPlease inform the doctor of all medications, supplements, or substances you use. Avoid benzodiazepines, Lamictal (Lamotrigine), or Keppra the morning of treatment. Do not consume alcohol, cannabis, diphenhydramine, hydroxyzine, or mirtazapine while undergoing therapy. 3. Possible Side EffectsRisks include but are not limited to: nausea, vomiting, dizziness, headache, hallucinations, bladder irritation, allergic reactions, insomnia, weight loss, and rare complications such as seizure, stroke, or cardiac events. Ketamine may worsen symptoms in patients with psychosis or mania. 4. Pregnancy WarningKetamine may cause fetal harm. You must inform us if you are pregnant, may become pregnant, or are trying to conceive. 5. Consent to Treatment & MonitoringYou must:Arrange transportation home. Do not drive for 12–24 hours post-infusion.Avoid food or drink for 4 hours prior (small sips of water for medications are allowed).Remain in observation until you are cleared to leave. Notify staff if you feel faint, dizzy, or unwell at any time. 6. Legal & Clinical DisclosuresYou understand this is an off-label treatment and no guarantee of cure is made. Ketamine may cause altered perception or memory during and shortly after infusions. You authorize the provider to administer additional medications as clinically necessary.If prescribed oral or intranasal Ketamine, you must avoid operating vehicles or machinery for at least 2 hours post-dose. 7. Ongoing Monitoring & CommunicationContinued prescriptions require follow-up every 3–4 months, which may include urine or blood tests.If therapy is deemed ineffective or unsafe, it may be discontinued. All communication via email is for convenience only—not for diagnosis, urgent care, or emergencies. 8. EmergenciesIf you are having thoughts of self-harm or suicide, call 911 or go to the nearest ER. You may also contact the Suicide & Crisis Lifeline at 988. 9. Cancellation PolicyAppointments must be cancelled at least 2 business days in advance to avoid a $200 fee. Membership holders who no-show twice will lose one session. By signing below, you confirm that:You have read this document and understand the risks and conditions. You have had an opportunity to ask questions. You accept the risks of Ketamine therapy and wish to proceed.*

Powered by Jotform SignClear
Should be Empty:

Deposit Form + Other Payment Options