If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required. First Name * Last Name * Today's Date * Date of Birth * Please type your initials after each statement: Ketamine is an anesthetic agent. At subanesthetic doses (doses below the amount necessary for general anesthesia), Ketamine is useful for the treatment of severe depression. * 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, Ketamine is efficient in about 70% of the cases and the effects typically last for about 2 weeks. Longer or shorter duration of action is possible. * Potential side effects from Ketamine include dizziness, bad dreams, perceptual disturbances, confusion, elevations in blood pressure, euphoria, increased libido, and nausea. These side effects mostly disappear 80 minutes from infusion, and Ketamine infusion is well-tolerated. * 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. Kaster and his team at Ketamine West Hartford to administer Ketamine for the treatment of my condition. * I understand that I can revoke this consent at any time, including during the infusion. * I understand that the duration of the infusion will be approximately one hour, and I understand that it will be necessary for me to stay in the office for a while after the infusion ends, typically a few more hours. * Patient Signature * Please type your full name into the area below.