What brings you to Vita Nova Ketamine & Wellness Clinic? *

Chronic Pain Relief

Mental Health & Emotional Wellness

How long have you been dealing with chronic pain? *

Less than 6 months

6–12 months

1–3 years

3+ years

On a scale of 1–10, how would you rate your current pain level? *

1–3 (Mild)

4–6 (Moderate)

7–10 (Severe)

How soon are you looking to get started? *

ASAP

Within 2 weeks

Within a month

Just exploring

How many antidepressants or medications have you tried? *

None

1–2

3–4

How soon are you looking to get started? *

ASAP

Within 2 weeks

Within a month

Just exploring

Ketamine therapy is self-pay. Insurance doesn't cover it. Are you able to pay for treatment out of pocket? *

Yes, I'm ready to pay out of pocket

No, I need insurance to cover it

Yes, but I'd like payment plan or HSA/FSA options

First Name *

Last Name *

Phone *

Email *

What's the best way to reach you? *

Phone call

Text message

Best time to reach you?

By checking this box, I consent to receive non-marketing text messages from Vita Nova Ketamine & Wellness Clinic about appointment scheduling, reminders and follow-up about my inquiry. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages, including updates and offers, from Vita Nova Ketamine & Wellness Clinic at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.