Authorization for Communication Form

This form provides Ketamine Wellness Center's therapist and clinical staff with written permission to communicate with other individuals regarding your treatment (e.g. previous therapist, current health care providers, parent, spouse).
  • Authorized Party

    Please provide the details of the party who Ketamine Wellness Centers will communicate information about your case to.
  • MM slash DD slash YYYY
  • This release shall be valid while under the care of Ketamine Wellness Centers, Inc. or until withdrawn in writing by the patient during the course of treatment.