Portland Ketamine Clinic Forms

Release of Medical Information

Your Name*
First Last

Your Email*

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.

I Authorize (Psychiatrist)*

Name of Psychiatrist. We only except referrals from medical Psychiatrists.

Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number of Psychiatrist*

Fax Number of Psychiatrist*

Email address of Psychiatrist

To Release My Health Information to the Office of:

Portland Ketamine Clinic
Dr. Enrique Abreu, Dr. Danyi

Phone: 503-207-4992
Fax: 503-961-1859

Description of Information to be Disclosed*
Choose one

Release of all of my health information that the provider has in his or her possession including information relating to any medical history, mental or physical condition and any treatment received by me.

Only the following records or types of health information.

If Checked Option 2: List Records or Types of Health information to be Disclosed.

List Any Other Doctors / Pain Specialists you would like to Authorized to Release Health Information

Signature Agreement of Patient or Legally Responsible Party*

Date*
MM slash DD slash YYYY

If Legal Representative, Relationship to the Patient

Is there anything else you would like the Doctor to know?

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Name
This field is for validation purposes and should be left unchanged.

Medical Intake Form

Intake Form