Membership Application

Name*

First Last

Yearly Membership Options*

Physician Membership (MD, DO) $400/yearly
Independent Non-Physician Practitioner Membership (CRNA, NP, PA) $400/yearly
Associate Membership (RN, LMSW, PhD, CRNA) $200/yearly
Resident Physician Membership $100/yearly

*membership rates are subject to change & for questions regarding membership category, please contact us at info@askp.org

Total

$0.00

Specialty

NPI Number

For physicians only. This number will used for verification purposes by ASKP personnel. It will not be posted publicly.

Board Certification

Name of your practice

How many locations?

Address of your practice

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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*

This number will used by ASKP 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*

This email will be used by ASKP 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?*

Yes
No

What disorders do you treat with ketamine?

Mood Disorders
OCD
Chronic Pain
CRPS
Migraine

How do you administer ketamine?

IM
PO
IN
IV

What forms of monitoring do you do during administration?

SpO2
BP
HR
EKG

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?

Yes
No

If so, most common form:

IN
IM
PO

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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Name

This field is for validation purposes and should be left unchanged.

AMERICAN SOCIETY OF KETAMINE PHYSICIANS