(For educational purposes ONLY, this extract has been reproduced with permission by Dr Stephen Hyde from his book, Ketamine for Depression)

Patient’s name:
DOB:
Procedure: administration of sublingual ketamine
Doctor’s Statement
In my opinion, there is no reason to doubt this patient’s capacity to make this decision.
I have explained the treatment to the patient. In particular, I have described the intended benefits, including:
• reduction in feelings of depression, anxiety, and obsessivecompulsive
symptoms
• reduced suicidal thoughts
• improved function.
I have also outlined significant, unavoidable, or frequently occurring risks, including short-term effects of dry mouth, dizziness, lightheadedness, feelings of unreality, and rarely, hallucinations.
Long-term effects are unclear, but cognitive difficulties, bladder problems, and elevated liver enzymes have been reported in some with regular high-dose usage.
I have also discussed:
• that this is an off-label use of ketamine
• what the procedure involves, including financial costs
• any particular concerns of the patient
• the risks and benefits of alternative treatments, including no
treatment.
I have provided the ketamine patient information leaflet.
Signed

Date
Name
Statement and Signature of Patient
You will be offered a copy of this form. You have the right to change your mind at any time, including after you have signed this form.
I have read the Patient Information Leaflet.
I understand the information that I have been given about the
treatment described on this form.
I agree to the course of treatment described on this form.
Patient’s signature:
Date: