Name (required)
Specialty
NPI Number For physicians only. This number will used for verification purposes by ABKP personnel. It will not be posted publicly.
Board Certification
Name of your practice
Street Address
Street Address Line 2
City
Postal / Zip Code
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If more then one location, please list below
Clinic Phone Number This is the number that will be posted on the clinic directory, if applicable.
Contact Phone Number (required) This number will used by ABKP personnel for membership issues. It will not be posted publicly. It may or may not be the same as the clinic phone number (above). This is a required field.
Clinic Email This is the email that will be listed on the store locator, if applicable.
Contact Email (required) This email will be used by ABKP personnel for membership issues, and will not be posted publicly, on the clinic directory, or otherwise. It is mandatory.
Website for your practice
Would you like your clinic(s) to be included in the clinic directory? (required)YesNo
How do you administer ketamine?IMPOINIV
What forms of monitoring do you do during administration?SpO2BPHREKG
What percentage of your practice pertains to ketamine administration?0 - 25%25 - 50%50 - 75%75 - 100%
Do you allow for home use of ketamine? (required)YesNo
What is your average dose and duration of ketamine infusions for mood disorders?
What is your average dose and duration of ketamine infusions for pain disorders?
What other services does your clinic offer?
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