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Patient Intake Form
Personal Information
(Required)
First
Last
Date of Birth
(Required)
Month
Day
Year
Phone
(Required)
Do you give our staff permission to leave a voicemail regarding your inquiry into Atlas Ketamine in the event we cannot reach you?
(Required)
Yes
No
Email
(Required)
Preferred Contact Method
(Required)
Phone Call
Email
No Preference
How did you find us?
(Required)
Google
Facebook
Personal Referral
Professional Referral
Website
Other
Emergency Contact Name
(Required)
Emergency Contact Phone
(Required)
What condition(s) are you seeking treatment for at our clinic?
(Required)
Depression
Post Traumatic Stress Disorder (PTSD)
Obsessive Compulsive Disorder (OCD)
Anxiety
Suicidal Ideation
Chronic Pain
Other
Please mark all that apply
Which of the following treatments are you interested in?
(Required)
Ketamine
PRP
Not sure
Health Information
Have you ever received any form of ketamine therapy (infusions, lozenges, Spravato, etc)?*
(Required)
Yes
No
List any current medications and the corresponding dose *
(Required)
If none, type "n/a" or "none"
Please list any known allergies *
(Required)
If none, type "n/a" or "none"
Please list any surgical procedure(s)s and approximate date(s) *
(Required)
If none, type "n/a" or "none"
Please list any or all anesthesia problems with you or your family members *
(Required)
If none, type "n/a" or "none"
Have you ever experienced any of the following heath problems? *
(Required)
Neurological/brain conditions (stroke, epilepsy, concussion, etc.)
Cardiac/heart conditions (high blood pressure, heart attack, heart murmur, etc.)
Gastro/liver/intestinal conditions (Crohn's, IBS, hepatitis, etc.)
Endocrinology (cancer, diabetes, thyroid, etc.)
Renal/kidney conditions (renal failure, dialysis etc.)
Pulmonary/lung conditions (asthma, COPD, tobacco use, etc.)
Orthopedic/bone conditions (fractures, rheumatoid arthritis, osteo-arthritis etc.)
Other conditions (fibromyalgia, pain syndromes, chronic pain, glaucoma etc.)
None of the above
Please list any current or resolved conditions in these areas.
Δ
Address:
18205 N 51st Ave STE 126,
Glendale, AZ 85308
Phone:
(602) 922-8527
Hours:
Mon - Thu: 7am–4:30pm
Fri: 8am–12pm
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