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Rejuvenate Mind & Body
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Intake form
Help us serve you better
Name
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Email address
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Message
Date of birth
Phone number
Have you previously received ketamine therapy?
Select
Yes
No
What are your primary concerns?
Please select at least one option.
Anxiety
Depression
Chronic pain
PTSD
List any medications you are currently taking
Do you have any history of substance abuse?
Select
Yes
No
Have you been diagnosed with any mental health conditions?
Please select at least one option.
Bipolar Disorder
Major Depressive Disorder
Generalized Anxiety Disorder
Schizophrenia
None
Do you have any allergies?
Have you had any surgeries in the past?
Select
Yes
No
If yes, please specify the surgeries
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