California Patient Forms

Select the intake form that matches your treatment at our Upland clinic

Upland Clinic

1060 E Foothill Blvd, Suite 203, Upland, CA 91786

Phone: 909-689-4900

Select Your Treatment Form

Choose the form that matches your planned treatment

Chronic Pain

Ketamine therapy intake form for chronic pain management

Complete Form

Depression

Ketamine therapy intake form for depression treatment

Complete Form

Drug & Alcohol Addiction

BR+NAD therapy intake form for addiction recovery

Complete Form

NAD+ Therapy

IV NAD+ and multivitamin therapy intake form

Complete Form

Medical Records Release

Download and submit your authorization form

Authorization to Release Medical Records

Your medical records assist us in tailoring your treatment to your specific conditions. Download this form, complete it, and forward to your managing professional.

Download PDF Form

Need Assistance?

If you have questions about which form to complete or need help, our team is here to assist you.