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):

Referral form

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

Confirmation of Care form

Established Patients:

For mental health infusions, please fill out and sign the Pre-Infusion Questionnaire, Ketamine Therapy After-Infusion Instructions, and Informed Consent forms prior to coming in for your infusion appointment. (These three 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, and Informed Consent forms prior to coming in for your infusion appointment. (These same forms need to be completed prior to every pain 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 assessment, Ketamine Therapy After-Infusion Instructions, and Informed Consent forms prior to coming in for your infusion appointment. (These four 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.