Intake Form PKC

Step 1 of 2

  • Please note: In order to be a patient at Portland Ketamine Clinic you must have a referral from a Psychiatrist. We can NOT accept referrals from ANY other mental health care providers incl. MHNP, therapists or psychologists.
  • Patient Intake Form for Portland Ketamine Clinic
    Patient Information
  • Date Format: MM slash DD slash YYYY
  • Can NOT be your name
  • Can NOT be your phone number
  • If you are not currently on any medication, Please type "NONE."