Part 1: General Information

Name *
Name
Phone *
Phone
When is the best time to contact you?
When is the best time to contact you?
Schedule your Counseling Session
When would you like to schedule your counseling session? *
When would you like to schedule your counseling session?
Your first counseling session takes place before your ketamine infusion. We assist you during the entire process.
Please select your counselor
With each infusion, you receive a $125.00 rebate towards a counseling session.
Counseling Session Preference
In person Counseling Sessions take place at your preferred counselors office.
Schedule your Ketamine Infusion
When would you like to schedule your ketamine infusion?
When would you like to schedule your ketamine infusion?
Subject to availability.
Subject to availability.
Subject to availability
Payment
Preferred Method
How would you like to pay for your experience?

PART 2: Medical Form

Upon submitting Part 1 of the form, you will be redirected to fill in Part 2 of this form.

We respect and value your privacy. Unless authorized, we never share your information.

Upon completion, a myKetamine Road representative will contact you and confirm your experience.