Patient name (First and Last) *

First Name

Last Name

Patient birthdate (must be 18 or older) *

MM

DD

YYYY

Patient address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does the Patient have a current diagnosis of Major Depression Disorder symptoms? *

Yes

No

Select one

F33.1

F33.2

Select One

90791

90792

Other

Has patient tried psychotherapy? *

Yes

No

Are you aware of any contraindicators? *

Yes

No

Have you discussed and recommended Spravato as an option with your patient? *

Yes

No

Other related health concerns (Seizures, Dementia, Stroke, Acute psychosis, Serious Illness, Non-adherence to Tx *

Yes

No