Ketamine Infusion Consent Form

Please read all sections carefully before signing. This form covers informed consent for ketamine infusion therapy with Edward Rubin MD.

Patient Information

Full Name *

Date of Birth *

Email Address *

A copy of this signed consent will be sent to this address.

Primary Diagnosis / Reason for Treatment *

Consent Form

Edward Rubin, M.D. P.C.

Ketamine has been used for decades as an anesthetic medication and is FDA approved for use as an anesthetic agent. Ketamine is not FDA approved for the treatment of chronic pain, depression, or psychiatric conditions. This treatment is not a clinical study and has not been reviewed by an Institutional Review Board (IRB).

Common Side Effects

The most common side effects include nausea, vomiting, increased saliva production, vivid or strange dreams, and feelings of dysphoria during the infusion. Vision changes and seizure-like movements may occur.

Less Common / Serious Risks

Less common but serious risks include events requiring cardiac intervention, heart attack, stroke, and death. These adverse events are much more likely to occur at high doses. The doses used during slow infusions (60–90 minutes) are significantly lower than those associated with serious adverse outcomes.

Treatment Schedule & Payment

Edward Rubin MD recommends a course of 6 treatments over 6 weeks to maximize therapeutic benefit. You may choose to alter your treatment schedule at any time, with the understanding that this may reduce the benefit you experience. Ketamine infusion treatment is paid upfront at the time of each infusion.

Ketamine Education — Patient Acknowledgments

The following statements reflect your understanding of ketamine therapy. By signing below, you confirm that each of the following applies to you.

1.I understand ketamine is an approved medication by the FDA, but Edward Rubin MD is using ketamine off-label for this treatment.
2.I acknowledge I have read this consent form, understand the risks of ketamine infusions, have been offered the opportunity to ask questions about ketamine, and agree to proceed with the planned infusion.
3.I accept all risks associated with the off-label use of ketamine.
4.I understand and acknowledge I am choosing to have the ketamine infusion by my own choice, and at any time I can halt treatment.
5.I understand and acknowledge I will contact Edward Rubin MD with any unusual symptoms or concerning signs following treatment.
6.I understand and acknowledge I will call 911 for any life-threatening symptoms I may experience after the infusion.
7.I understand and acknowledge that ketamine is not guaranteed to provide any benefit, and I may receive no benefit or may have worse symptoms even after repeated infusions.
8.I understand and acknowledge the potential side effects of ketamine, including nausea, vomiting, euphoria, perceptual disturbances, vivid or unusual dreams, confusion, changes in heart rate, changes in blood pressure, difficulty breathing, anxiety, increased saliva production, musculoskeletal disruptions, increased pressure in the lungs, rash, double vision, and unusual heart rhythms.
9.I understand that these side effects are much more likely at doses significantly higher than what I will be receiving during slow infusions lasting approximately 60–90 minutes.
10.I understand that ketamine infusion is part of my treatment plan, not a replacement for other care, and I will continue to be compliant with my physician's recommendations.
11.I understand that Edward Rubin MD has the right to refuse treatment to me at any time without cause.
12.I understand and acknowledge the pricing for Edward Rubin MD treatment and will pay as agreed. I maintain full financial responsibility.
13.I understand that I must notify the office at least 72 hours in advance if I need to cancel or miss my scheduled treatment, or I may be charged $100 to reschedule.
14.I understand the symptoms and benefits of ketamine therapy. Many patients experience significant benefit after a single treatment. Benefits may take 2–3 weeks to appear as reported in the medical literature.
15.I understand and acknowledge I have been informed not to drive or operate heavy machinery on the day of treatment, consume alcohol, make financial or business decisions, sign legal documents, or engage in activities requiring fine motor skills — as ketamine can cause memory disturbances, disorientation, and impaired judgment during and after treatment. Acting against this advice is acting against medical advice.
16.I understand and acknowledge that I have provided Edward Rubin MD with all of my relevant medical history, current medications, and pertinent medical information.

Acknowledgment & Signature

I have read and understand this consent form and the Ketamine Education acknowledgments. I understand the risks, benefits, and limitations of ketamine infusion therapy and give my written consent to proceed.

Patient Signature *

Your signed consent will be sent securely to Dr. Rubin's office and a copy to your email.