INTAKE FORM

Prospective New Patient Demographics

In preparation for your first visit with Said A. Ibrahimi, M.D., Vortex Psychiatry, we will need some information.

Once we have verified your insurance benefits, a member of our staff will contact you as soon as possible to schedule your appointment. Please complete the information below.

Patient First Name

Patient Last Name

Patient Date Of Birth:

Patient Email

Best Contact Phone Number

Reason for Appointment:

Who were you referred by?

Insurance Provider (if applicable):

Insurance Name

Insurance Subscriber or ID Number

Please include Mental Health/Provider Services Phone Number: (Can be found on front or back of insurance ID card)

PATIENT INFORMATION

Patient Name

Date of Birth

Gender

Patient Address (Street, City, Zip Code)

Primary Contact Phone

Secondary Contact Phone

RESPONSIBLE PARTY NAME

Responsible Party's SSN

Address Street, City, Zip Code (If different)

Home Phone (If different)

Work Phone (If different)

Cell Phone (If different)

Please select which phone numbers we may NOT leave a message.

Patient's relationship to Responsible Part:

Self Spouse Child Other

Relative or friend in case of emergency

Name

Phone Number

Relationship

Source of referral

Reason of referral

How did you hear about Mental Wellness Counseling?

FINANCIAL

I understand that The Injection & Infusion Clinic of Vortex Psychiatry does not accept insurance for Ketamine Infusion treatment. Upon request, I will be given a receipt that I may submit to my insurance for possible reimbursement. As well, I understand that if I cancel within 24 hours or do not show up for an appointment, I will be billed the entire amount of the appointment. I have been given the opportunity to ask questions regarding this statement. We ask for a credit card to be kept on file. Any charges owed on your account balance past 30 days after insurance has been billed, or private pay accounts, will be charged 30 days after date of service. All annual fees effective December 1, 2023 will be charged as a new patient at the time of service, and follow up patients at the next date of service.

Signature of Responsible Party

Printed Name

Date

Name and type of Credit Card

EX: Visa/Master/Discover/AMEX

Credit Card/ Debit Card Account Number

type full credit card/debit account number

Credit/Debit card expiration date

Indicate Month/Day/Year of expiration

INTAKE FORM

Patien Full Name

3. Date of Birth

4. Weight

5. Height

8. Occupation (if retired, previous work)

9. Emergency Contact (Name and Phone Number)

10. Primary Doctor (Name and Phone Number)

if you would like Dr. Ibrahimi to speak with your PCP or other Provider regarding your care, please complete the Consent to Release Form locate on our website.

11. Psychiatrist (Name and Phone Number)

12. Referred By?

13. Past Medical History

14. Psychiatrist History

15. Surgical History

16. Spiritual Beliefs and/or Religion

17. Current Medications

Indicate name, dosage, and frequency of each medication.

18. Allergies (and reactions)

19. Have you ever had an adverse reaction to anesthetic medications?

Yes No

20. Have you ever had a psychiatric hospitalization?

Yes No

21. Family Medical and Psychiatric History

22. Please check any use of the following drugs:

Tobacco

Alcohol

Marijuana

Cocaine

Psilocybin

MDMA

Ayahuasca

LSD

Other

25. What is your primary goal for ketamine infusions?

26. Anything else important that must be mentioned?

27. I certify that I have completed this questionnaire to the best of my knowledge by signing my name below:

Signature of Responsible Party

Print Name

Date

Informed Consent for Ketamine Infusion Therapy

Ketamine is approved by the FDA for use in children and adults for anesthesia and as a pain reliever during medical procedures. When administered in a low-dose infusion, ketamine is a medication that may provide relief of symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and acute and chronic pain. Ketamine's use for the treatment of pain, depression, or other mental illnesses is off-label. Off-label use of medications is legal and very common. In fact, about one in five prescriptions written in the US today is off-label.

Why Is Ketamine Being Recommended?
Numerous studies show that ketamine may be helpful in the treatment of depression, anxiety, PTSD, acute and pain. When administered by vein over a period of 40 minutes up to 4 hours (called an infusion), ketamine may help improve symptoms rather quickly. Improvements may last several days up to a few months. A series of infusions is recommended so that symptom relief has a longer duration of action. While the goal is an improvement of symptom individual results cannot be guaranteed.

What Will Be Done?
You will be receiving ketamine by IV Infusion. This means an IV catheter will be inserted into a vein of your hand or arm and a ketamine fluid will be dripped into the vein. During the infusion, your level of sedation, blood pressure, heart rate, oxygen concentration, heart rhythm, and respiration will be monitored. After the treatment, you will need time to recover in the office and may take some sips of fluid during the recovery period. For depression, current research recommends that you receive 6 treatments over about two weeks as the primary treatment episode. Additional maintenance treatments may or may not be suggested, occurring about once a month or less frequently as recommended by your infusion provider. For pain, the frequency of Ketamine infusions is based on your specific type of pain and response to therapy.

What Safety Precautions Must You Take?

You may not eat or drink 8 hours before the infusion, water is the only exception. You may drink water up to 2 hours before the infusions.
You may NOT drive a car, operate hazardous equipment, or engage in hazardous activities for at least 24 hours after each treatment as reflexes may be slow or impaired. Another adult will need to drive you home and must be present prior to your discharge.
You must refrain from a alcohol 24 hours prior to and following ketamine administration. You must refrain from other illegal substances during your ketamine infusion treatment.
You must tell the clinic about all medications you are taking, especially narcotic pain relievers,
benzodiazepines, barbiturates and muscle relaxers.
To qualify to receive ketamine therapy for mental health conditions, you must notify and share the contact information for the mental health provider treating your psychiatric symptoms or your curent primary care provider.
If you experience a minor side effect while you are at home, you should contact the Infusion Clinic (800-679-4951), otherwise contact your medical provider or call 911.

What Are the Possible Side Effects of Ketamine?

Possible side effects may include and are not limited to:

fast or irregular heart beats
increased or decreased blood pressure
vivid dreams
confusion
irritation or excitement
floating sensation ("out-of-body")
twitching, muscle jerks, and muscle tension
confusion
urinary frequency
increased saliva or thirst
lack of appetite
headaches
metallic taste
constipation
blurry or double vision
nausea or vomiting
memory changes

Rare side effects of ketamine are:

allergic reactions
pain at site of injection
increase in pressure inside the eye
inflammation in the bladder
respiratory complications
hallucinations
euphoria
involuntary eye movements
low mood or suicidal thoughts

Side effects of receiving of IV are:

mild discomfort at the site of placement
bruising
infiltration
infection

Important Notices and Agreements:

KETAMINE INFUSION THERAPY IS NOT A COMPREHENSIVE TREATMENT FOR DEPRESSION, ANXIETY OR ANY PSYCHIATRIC SYMPTOMS Your ketamine infusions are meant to augment(add on to, not be used in place (comprehensive psychiatric treatment. Therapy is a recommended adjunct.
While receiving ketamine infusions, you agree to remain under the care of a qualified primary care or mental health provider and have your overall health care directed by him or her
Psychiatric illnesses carry the risk of suicidal ideation (thoughts of ending one's life) or thoughts of harming others. Any such thoughts you may have at any time during your ketamine infusion therapy, or at any point in the future, which cannot immediately be addressed by visiting with a mental health professional should prompt you to seek emergency care at an ER or to call 911.
(Women only) Ketamine use during pregnancy is not generally recommended. Females will be asked to submit a urine sample for a pregnancy test prior to your first infusion and every 2 weeks thereafter.

My Consent for Ketamine Treatment is Voluntary:
My request for ketamine infusion treatments as described is entirely voluntary and I have not been offered any inducement to consent. I understand that I may refuse ketamine treatments at any time. Any money I have deposited for future treatments will be refunded to me if I choose not to proceed with future infusions. I have been advised that I can seek a second opinion from another provider before agreeing to have ketamine treatment and I am choosing to proceed at this time, with or without this second opinion. I have notified my mental health provider and/or primary care provider of my ketamine infusion therapy.

Statement of Person Giving Informed Consent

I have read this consent form and understand the information contained in it. I understandthe risks and benefits and have had the opportunity to have all my questions answered tomy satisfaction.
I have had the opportunity to ask questions about this procedure. I consent and would like to proceed with ketamine infusion treatment.

Signature of Responsible Party

Date

Time

Signature of Witness:

Date

Time

The provider treating my symptoms of depression or anxiety or other psychiatric symptoms is:

Name:

Phone Number:

Fax:

Email address

Address:

RELEASE OF MEDICAL INFORMATION

In case of emergency, I hereby authorize my ketamine provider to disclose my medical records, to EMS and to the individual listed above or the appropriate personnel in his or her office. I further authorize the individual listed above to disclose my medical records, including any history of substance use or abuse, to my ketamine provider, or appropriate personnel in his or her office. I also authorize my ketamine provider to discuss my care and share my medical information for the purposes of monitoring, quality control or safety concerns.

EMERGENCY CONTACT

My Emergency Contact is:

Name:

Phone Number:

Relationship to patient

Address:

I hereby authorize my ketamine to disclose my medical condition to the above person in the event of concern about my post procedure recovery or any emergency situation so that this person may assist me as needed.

Signature of Responsible Party

Date

Ketamine Consent Form

Patient Name:

Date

Date of Birth:

Infusion #:

Office to complete

Allergies:

Treatment: Administration of intravenous ketamine for non-anesthetic indications (KNAI)

Doctor's Statement:

In my opinion, there is no reason to doubt this patient's capacity to make this decision. I have explained the treatment to the patient. In particular, I have described the intended benefits, potentially including:

Reduction in feelings of depression, anxiety, PTSD, and obsessive-compulsive symptoms
Reduced suicidal thoughts
Improved function in life
Reduction in pain from headache, fibromyalgia, neuropathic pain, and CRPS / RSD

I have also outlined significant, unavoidable, potential and/or frequently occurring risks, including short-term effects of increased anxiety, increased blood pressure, dizziness, lightheadedness, feelings of unreality, hallucinations, cardiac arrhythmias, salivation, rashes, psychosis, and/or misperceptions.

Long-term effects are unclear, but cognitive difficulties, bladder problems, and elevated liver enzymes have been reported in some with high-dose and frequent usage.

In certain cases, we may need to administer IV medications for: nausea/vomiting, hypertension, allergic reactions, and/or severe anxiety.

We may add magnesium, lidocaine, and/or other medications prior to your infusion, which we will let you know before the infusion begins.

I have also discussed:

that this is an off-label use of ketamine
that the patient may or may not experience improvement
what the treatment involves, including financial costs, and need for maintenance infusions
any particular concerns of the patient
agreement that patient will not drive or operate heavy machinery for 12 hours after treatment
the risks and benefits of alternative treatments, including no treatment

Signature of Responsible Party

Date

Statement and Signature of Patient

You will be offered a copy of this form. You have the right to stop treatment at any time, including after you have signed this form.

I understand the information that I have been given about the treatment described on this form.

I agree to the course of treatment described on this form.

Signature of Responsible Party

HIPAA Compliance Patient Consent Form

For Vortex Psychiatry

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIP AA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such revocation will not be retroactive.

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The practice reserves the right to change the privacy policy as allowed by law.
The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon the execution of this consent.

Please answer the following:

May we phone, email, or send a text to you to confirm appointments?

YES NO

May we leave a message on your answering machine at home or on your cell phone?

YES NO

May we discuss your medical condition with any member of your family?

YES NO

This consent was signed by:

Signature of Responsible Party

Date

Practice Policies

You will be evaluated, trained, and by a licensed provider. We wish to take this opportunity to welcome you and also to state some basic principles we believe are essential in establishing a good relationship between us. Please read through this information, asking questions as needed.

1. INITIAL INTERVIEW: Your first history and physical is considered an evaluation interview and exam. At the time of this appointment, the following decisions will be made with you:

If ketamine is an appropriate treatment option
Frequency of ketamine infusion sessions
Goals of therapy (what you hope to gain from this process.)

2. APPOINTMENTS: Each appointment varies in length depending on your chief complaint. Typically, 40 min infusion appointments take just under 2 hours, At the end of each appointment, you can make arrangements for your next appointment, or you may also book all your prescribed appointments at once.

3. CANCELLATIONS: If you find that you need to cancel an appointment, please give us much notice as possible so that we can schedule people that are on our waiting list. You will be personally charged for your appointment if not canceled at least 24 hours in advance other than for emergency reasons.

4. PAYMENTS: We would greatly appreciate payment in full for each office prior to the start of your appointment. If you do not have a charge card. We will accept cash and credit cards.

5. INSURANCE: Insurance is an agreement between you and your insurance company as to how treatment will be paid for. We will assist you in any way possible by providing receipts and documentation. We currently do not directly participate with insurance plans for Ketamine Infusion treatment. However, we will assist you by giving you receipt; to submit, and follow-up contacts. Some insurance companies will pay for a portion of outpatient ketamine infusion services. You should check with your insurance company representative to find out the specific requirements and limitations of this coverage. We will be happy to assist you in the preparation of insurance forms if you feel there is a chance your insurance company will pay for these services. The hourly rate will apply. Payments for services received through Vortex Psychiatry are ultimately your responsibility. If your insurance company requires that outpatient ketamine infusion services be preauthorized, it is your responsibility to initiate the preauthorization process, i.e. contacting your primary care physician, insurance company, or a third party "gatekeeper". Failure to obtain the required preauthorization for outpatient mental health services will result in you being held 100% responsible for all charges.

6. CONFIDENTIALITY: All information regarding the specific nature of your treatment is maintained at The Injection & Infusion Clinic of Vortex Psychiatry and is considered confidential within the office unless specified by you in writing. However, each provider at this office reserves the right to use specialty consultation with other medical providers at the office as deemed necessary. We follow HIPAA and maintain confidentiality.

Please check the initial boxes.

I acknowledge that I have read and understood ail of the foregoing statements and that my signature below indicates that I agree to abide by all of the above conditions.

Yes No

I have received a copy of the Privacy Practices Form.

Yes No

I consent to the exchange of treatment information between Vortex Psychiatry and my primary care or mental health provider.

Yes No

Signature of Responsible Party

Date

Discharge Instructions and Recommendations

Do not drive a car or operate heavy machinery for 12 hours after your infusion.

Do not drink alcohol for 24 hours after your infusion.

Avoid solid food for the next 1 hour, and drink liquids instead.

Your next appointment:

Said A Ibrahim | MD
925-648-2650
4155 Blackhawk Circle Plaza
suite 240
Danville, CA 94506

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