PLEASE REVIEW AND COMPLETE THE WAIVER OF LIABILITY

On the day of the infusion, you should NOT engage in any of the following after the infusion:

• • Driving
  • Drinking alcohol or using drugs including marijuana products
  • Conducting business
  • Participating in activities which require you to rely on motor skills or memory

While you are receiving ketamine infusions at Vitalitas Denver, P.C. you agree that you will not use any recreational drugs or abuse alcohol as active substance abuse is a contraindication to ketamine therapy and grounds for possible termination of treatment and dismissal from the practice.

We advise you not to drink alcohol 48 hours before and 48 hours after your ketamine infusion as this may potentially inhibit the effects of the ketamine infusion.

By agreeing to this treatment and by your signature on this form, you recognize and understand the risks involved and agree to strictly adhere to these policies after every administration of the medication.

In the event you decide to engage in the above-listed activities, you agree you do so at your own peril. In no event will Vitalitas Denver, P.C., its staff, physicians, employees, or agents (collectively “the Practice”) be liable in any way for any personal injury, death, property loss or damage sustained by or through you in connection with my engagement after infusion in the above-listed activities. By your signature below, you agree to waive, release, and discharge the Practice from any and all liability, claims, demands, actions, and causes of actions whatsoever for any and all loss, claim, damage, injury, illness, fees or harm arising out of your participation after an infusion in the above-listed activities.

This waiver will remain binding and in effect so long as you participate in treatment with Vitalitas Denver, PC