(if prescribed by a Provider)

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I, the (“Patient”) hereby give my consent to Goal Mind and its licensed healthcare providers to treat my depression, anxiety, PTSD, OCD, drug or alcohol abuse with administration of the drug, ketamine, if my Provider determines such treatment is appropriate. I acknowledge that treatment of depression, anxiety, PTSD, OCD, drug or alcohol abuse is an off-label use for ketamine, which means that such use has not been approved by the U.S. Food & Drug Administration (“FDA”).

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About Ketamine

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Ketamine is a synthetic pharmaceutical compound consisting of a mixture of two mirror image molecules, R- and S- ketamine. Ketamine is classified as a Scheduled III controlled substance by the U.S. Drug Enforcement Administration (DEA) and is approved by the FDA in injectable forms for induction and maintenance of general anesthesia. The S-form of ketamine (called “esketamine”) is also a Schedule III controlled substance and was approved by the FDA in 2019 in nasal spray form for use with an oral antidepressant to treat adults with treatment-resistant depression and depressive symptoms in adults with major depressive disorder with suicidal thoughts or actions. The FDA has not approved any oral form of ketamine for

any use.