Forms

Forms

New Patients:

If you are interested in possibly becoming a new patient with us, please submit our TWO quick online forms: the “New Patient Clinical History” form located here  and our “Medical Records Release” form here. (If you are seeking treatment for chronic pain, please submit this third online form as well.) Our secure server is encrypted and HIPAA compliant to ensure your confidentiality. If you prefer, you may instead print, fill out, and then fax them to (720) 307-0992.  After we receive these forms, we will contact you to proceed further.

Referring Providers:

Please fill out the referral form if you are referring a patient (and/or call us at (303) 823-4882):

Providers may also use this form to confirm that a patient has been under their care:

Established Patients:

For mental health infusions, please fill out and sign the Pre-Infusion Questionnaire, Ketamine Therapy After-Infusion Instructions, COVID-19 Screening, and Informed Consent forms prior to coming in for your infusion appointment. (These four forms need to be completed prior to every infusion.) You should not sign the Informed Consent Form if you have any questions about the procedure. If this is the case, contact us so you can speak with Dr. Grindle prior to signing the form.

For chronic pain infusions, please fill out and sign the Post-pain infusion assessment, Ketamine Therapy After-Infusion Instructions, COVID-19 Screening, and Informed Consent forms prior to coming in for your infusion appointment. (These four forms need to be completed prior to every infusion.) You should not sign the Informed Consent Form if you have any questions about the procedure. If this is the case, contact us so you can speak with Dr. Grindle prior to signing the form.

For combined mental health and pain infusions, please fill out and sign the Pre-Infusion Questionnaire, Post-pain infusion assessmentKetamine Therapy After-Infusion Instructions, COVID-19 Screening, and Informed Consent forms prior to coming in for your infusion appointment. (These five forms should be completed prior to every infusion.) You should not sign the Informed Consent Form if you have any questions about the procedure. If this is the case, contact us so you can speak with Dr. Grindle prior to signing the form.

  1. Depression and Anxiety survey (for mental health infusions)
  2. Post-pain infusion assessment (between pain infusions)
  3. Ketamine Therapy After-Infusion Instructions
  4. COVID-19 Screening Form
  5. Informed Consent Form