Medical History Form

Virginia Infusion Therapies

Please tell us about your medical history. This information is important for us to design a treatment program specifically for your symptoms and needs.

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History of Substance Use
For each substance listed, please describe how much you use, how often you use it, when you used it last, and for how many years you have been using it?
Review of Systems
Please check off the various symptoms you are experiencing for each bodily system.

ACKNOWLEDGEMENT OF PAYMENT & CANCELLATION | WAIVER OF LIABILITY | KETAMINE PRICING & PAYMENT | CONSENT TO ELECTRONIC COMMUNICATION | PREGNANCY WAIVER | INFORMED CONSENT TO KETAMINE TREATMENT | PRIVACY POLICY | MEDICAL RELEASE | MEDICAL HISTORY

Virginia Infusion Therapies

The First Ketamine Clinic in Northern Virginia

Virginia Infusion Therapies is one of the the first Ketamine Clinics in Northern Virginia, and the first clinic in Loudoun County to provide Ketamine infusion therapy for the treatment of Major Depression and Pain Conditions.  The clinic was established by four physicians in Loudoun who, through their professional experiences in medicine and their personal family experiences with depression, recognized that there are major problems in the recognition and treatment of depression.  They recognized that Major Depression, Post-Traumatic Stress Syndrome, and some pain conditions are often medical emergencies that requires treatments that are more effective…  and more effective IMMEDIATELY.  

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