Provider Name and Credentials
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Provider Phone Number
(###)
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Provider Email
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Patient Name
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First Name
Last Name
Patient Date of Birth
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MM
DD
YYYY
Patient Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Patient Phone Number
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(###)
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Patient Email
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Date of Diagnosis
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MM
DD
YYYY
1. Medication (List name and dose)
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2. Medication (if applicable, list the name and dose)
3. Medication (if applicable, list the name and dose)
4. Medication (if applicable, list the name and dose)
5. Medication (if applicable, list name and dose)
1. Medication (List name, dose, date started, date stopped)
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2. Medication (List name, dose, date started, date stopped)
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3. Medication (List name, dose, date started, date stopped)
4. Medication (List name, dose, date started, date stopped)
5. Medication (List name, dose, date started, date stopped)
Please copy and paste last clinical notes. Additionally, provide any relevant clinical notes below (history and physical)
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1. Little interest or pleasure doing things?
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2. Feeling down, depressed, or hopeless
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3. Trouble falling or staying asleep, or sleeping too much
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4. Feeling tired or having little energy
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5. Poor appetite or overeating
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6. Feeling bad about yourself or that you're a failure or have let yourself or your family down
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7. Trouble concentrating on things, such as reading the newspaper or watching television
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8. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual
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9. Thoughts that you would be better off dead, or thoughts of hurting yourself
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Total Score (Add up your patient's answers from #1-9 for a total)
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CLINICAL NOTE AND AGREEMENT:
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It is in my medical opinion, based on scientifically valid studies, using accepted protocols, that Spravato is likely to be beneficial to the patient's mental health. This patient has failed TWO or more appropriate medications during this episode of depression. Patient has no current substance abuse disorder or medical disorder that would disqualify the patient from Spravato.
SEND A COPY OF FRONT AND BACK OF PATIENT'S INSURANCE CARD
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I Agree to Email a copy of the Patient's Insurance Card Front and Back to ivketamineofnwa@gmail.com. Once you have submitted this form, there is a box below where you can email the insurance cards, the email address show automatically pop up for you to make it easy.
