This patient and I would like to initiate ketamine infusion therapy as an adjunct to the management of the above illness. I acknowledge that I may review information about this therapeutic option at www.ketamineclinicofwesttexas.com and that I may contact Ketamine Clinic of West Texas to discuss the treatment. I will follow up with this patient during and after the completion of the treatment course at Ketamine Clinic of West Texas or refer him or her to a licensed medical professional for follow-up.