FREE Consultation 844.948.6337 | Financing Available | Financial Assistance Available | NEW Wellness Services

PATIENTS
TREATMENTS
RESOURCES
MEDIA/PRESS
BLOG
VETERANS
ABOUT
CONTACT

PATIENTS
TREATMENTS
RESOURCES
MEDIA/PRESS
BLOG
VETERANS
ABOUT
CONTACT

IV Solution/Chicago Ketamine Centers

INFORMED CONSENT FOR KETAMINE THERAPY

Before you participate in the ketamine infusion therapy for depression or chronic pain, it is important that you completely understand the procedure, its benefits, and its risks. Please understand that the procedure is voluntary and that you have the right to stop at any time. Read the below statements carefully and initial in the space provided. Then read the final statement and sign and date this consent.
Instructions
- Ketamine is an anesthetic agent. At subanesthetic doses (doses below the amount necessary for general anesthesia), Ketamine is useful in the treatment of Major Depression and Chronic Pain.
- Use of Ketamine for the treatment of Major Depression is considered investigational by the Food and Drug Administration, although it is supported by multiple clinical studies.
- According to the literature, Ketamine is efficient in up to 80% of the cases and the effects typically last for up to 2 weeks after a single infusion. Longer duration of action is likely after multiple infusions.
- You cannot drive yourself home from the treatment and should not drive until the next day.To do so is against medical advice and IV Solution will not be liable for property damage, physical injury and/or death to you or others.
- Potential side effects from ketamine include dizziness, vivid dreams, perceptual disturbances, confusion, elevations in blood pressure, euphoria, dizziness, mild fatigue, and nausea. These side effects mostly disappear within 90 minutes from infusion and Ketamine infusion is well tolerated.
- Ketamine is not physically addicting, but may psychologically addicting in those using it recreationally at much higher doses and in far greater frequencies than we will use.
- I have been explained thoroughly about the use of Ketamine for Major Depression and I had the opportunity to ask all the relevant questions I felt necessary.
- I voluntarily request Dr. Nandra, his providers, and the team at IV Solution to administer Ketamine for the treatment of my condition.
- I understand that I can revoke this consent at any time including during the infusions.
- I understand that the duration of the infusion will be approximately one hour and I understand that it will be necessary for me to stay in the clinic after the infusion ends and until I am discharged by my provider(s).
I know that ketamine is not a FDA approved treatment for depression. I know that my taking part in this procedure is my choice. I know that I may decide not to take part or to withdraw from the procedure at any time. I also know that the doctor may stop the infusion without my consent. I have had a chance to ask the doctors and staff questions about this treatment. They have answered those questions to my satisfaction. The nature and possible risks of a ketamine infusion have been fully explained to me. The potential benefits, the risks, and the possibility of complications have been fully explained to me. No guarantees or assurances have been made or given by anyone as to the results that may be obtained.
- I state by my signature below that I have read the information above.
- I know the conditions and procedures of the treatment.
- I know the possible risks and benefits from taking part in this treatment.
- I know that I do not give up my legal rights by signing this form.
Patient Name*
Signature
Date
MM slash DD slash YYYY
Signature
Date
MM slash DD slash YYYY

Δ

Ketamine Therapy IV Soln

chicagoivsolution Members of the American Society of Ketamine Physicians

Copyright ©2026 IV Solution and Ketamine Centers of Chicago | Site by Avola Technologies | Sitemap