Patient Forms

Offices in Rockville and Reston. Also offering mobile appointments in-home.

6000 Executive Boulevard #602 Rockville, MD 20852

11250 Roger Bacon Dr, Suite 12, Reston, VA 20190

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Three Ways to Complete Patient Onboarding:

By downloading the Osmind app: Osmind is a HIPAA-compliant healthcare system that many providers use to securely share data information with patients. Onboarding takes about five minutes. Click here for more information and to download the app.
By using the patient forms below: Please fill out the form below and print the remaining documents to complete at home and bring to your appointment.
In our office: If you’re not comfortable with Osmind or filling out the forms below, you can ask for a paper form when you come in for your first visit. Please note: this may cause delays in your appointment time, and we encourage you to arrive twenty minutes early to your appointment if you choose this method.

Freedom Ketamine Treatment Center Rockville and Reston (1).jpg

Welcome to Freedom Ketamine Treatment Centers

Welcome to Freedom Ketamine Treatment Centers. We are a leading provider of ketamine infusions in and around the Washington D.C. metro area. Ketamine infusions are an innovative and highly-effective treatment for depression, anxiety, PTSD and other psychiatric disorders, as well as for a variety of chronic pain conditions. Our Rockville, MD and Reston, VA ketamine offices providers of ketamine for depression, PTSD, anxiety, chronic pain and more.

Step 1: Registration & Ketamine Infusion Treatment Consent

Patient Consent Form

STEP 1 – REGISTRATION AND KETAMINE INFUSION TREATMENT CONSENT For new patients only.

First Name

Last Name

Phone

Date of Birth

Please check the boxes to acknowledge your understanding and consent of and to the following:

Ketamine is an anesthetic agent. At subanesthetic doses (doses below the amount necessary for general anesthesia)

Use of Ketamine for the treatment of major depression and other psychiatric conditions is considered investigational by the Food & Drug Administration (FDA).

According to the literature

Potential side effects from Ketamine include dizziness

There is a small but greater than zero risk of habituation with Ketamine.

I have been explained thoroughly about the use of Ketamine for major depression and I had the opportunity to ask all the relevant questions I felt necessary.

I voluntarily request Dr. Verdun and his team at Freedom Depression Treatment Center

I understand that I can revoke this consent at any time

I understand that the duration of the infusion will be approximately one hour

Thank you for submitting!

Step 2: Complete New Patient Intake Paperwork and Bring it to your Appointment

Step 3: Complete Health Questionnaire

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Monday – Friday: 8:00 AM – 8:00 PM
Saturday & Sunday: 8:00 AM – 6:00 PM

Our Locations

6000 Executive Boulevard #602 Rockville, MD 20852

11250 Roger Bacon Dr, Suite 12, Reston, VA 20190

Also offering in-home infusions across the DMV.

Call: 301-235-9022