Innovative Psychedelics Consult Request Form

Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

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Medical Condition*

DepressionSevere AnxietyChronic PainTraumaOther
Other Medical Condition
Have you ever had IM or IV Ketamine before?*

YesNo
Which Innovative Psychedelics clinic are you interested in visiting?*

Chicago - 3221 N Sheffield Avenue, C-1S Chicago, IL 60657Downers Grove - 136 Ogden Avenue, Downers Grove, IL 60515No Preference
How did you hear about us?*
Please selection one.
How did you hear about us?
Is there anything else we should know?
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