Forms

Forms

New Patients:

If you want to get started with us, we need you to fill out the quick three forms below (and the fourth form also if you are seeking treatment for chronic pain) and submit them online via our secure server. This is encrypted and HIPAA compliant to ensure your confidentiality. If you prefer, you may instead print them, fill them out, then fax them to (720) 307-0992.  After we receive these forms, will contact you to proceed further.

Until you have completed and submitted the “Consents and Authorizations form”, you should not communicate confidential or health information by email, text, or voicemail.

  1. Consents and Authorizations
  2. New Patient Clinical History form
  3. Medical Records Release form
  4. Chronic Pain History form

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:

Established Patients:

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 until you have discussed the procedure with Dr. Grindle, and had all of your questions explained, if any, before your infusion.