Additional Information

To expedite your first appointment and provide our team with more information to allow us to provide the highest level of care, please take a moment to fill out this optional questionnaire. Our Patient Care Team will follow up with you within 24 hours.

IV ketamine isn't a fit for certain people. If you are in a life threatening situation, call the National Suicide Prevention Line at *988 or visit your nearest emergency room. Responses are not monitored in real-time by NYKI.

Please confirm your information is correct.

First Name *

Last Name *

Phone *

Email *

How familiar are you with the benefits of ketamine therapy for anxiety and depression? *

I’d never heard about ketamine therapy until today

I have heard a little about ketamine therapy

I’m very familiar with ketamine’s therapeutic potential

Are you currently taking any of the following medications: Benzodiazepines, Gabapentin, or Lamotrigine? *

Yes

To provide the best treatment we need to know if any of the following apply to you: *

Under 18

Primary psychotic disorder (e.g. schizophrenia, schizoaffective disorder)

Biological female who is pregnant, nursing or trying to conceive

Uncontrolled high blood pressure despite treatment

You consider yourself to be dependent on alcohol or any other substances

I've been hospitalized in the past 30 days for a mood disorder

None of the above

I understand that as a new patient of NYKI, it is recommended that I complete an initial series of six infusions over the course of a two week period. *

Yes

I understand the cost of treatment and that each individual treatment cost $525 for a total cost of $3,150, and is typically not covered by insurance. Patients choose to return for 3-6 booster treatments over the course of 12 months. *

Yes

Acknowledgement: I hereby confirm that I have answered all questions honestly and to the best of my ability. Please click submit below to complete the form. *

I agree