SPRAVATOTM (esketamine) CIII Nasal Spray is indicated, in conjunction with an oral antidepressant (AD), for the treatment of treatment-resistant depression (TRD) in adults. SPRAVATOTM is not approved as an anesthetic agent. The safety and effectiveness of SPRAVATOTM as an anesthetic agent have not been established.

SPRAVATO is used along with an antidepressant taken by mouth to treat Adults with treatment-resistant depression (TRD) and depressive symptoms in adults with major depressive disorder (MDD) with suicidal thoughts or actions. The appropriate dosage is determined by your physician and is below those necessary to induce general anesthesia.

SPRAVATOTM is a non-competitive N-methyl D-aspartate (NMDA) receptor antagonist indicated, in conjunction with an oral antidepressant, for the treatment of treatment-resistant depression in adults. I, ____________________________ hereby give my consent to the following procedure.

Case Number: By signing this form, I acknowledge that the following has been explained to me and I understand and agree to the following: No food 4 hours prior to treatment with Spravato as it may cause nausea and vomiting I understand that …

evoke this consent at any time including during treatment. I understand that SPRAVATOTM nasal spray is indicated, and FDA approved, in conjunction with an oral antidepressant, fo. the treatment of treatment-resistant depression in adults. I fully consent and agree the Greater Houston Psychiatric Associate.

I understand that SPRAVATO nasal spray is indicated and FDA approved, in conjunction with an oral antidepressant, for the treatment of treatment-resistant depression in adults. I fully consent and agree to Massachusetts Mind Center to bill my insurance company for services rendered.

CenterINFORMED CONSENT FOR ADMINISTRATION OF SPRAVATO® X2116-0724

understand that my SPRAVATO treatment can be discontinued at any time if my provider deems it medically appropriate. ______ understand that I can revoke this consent at any time, …

The information contained in this consent form is also described in the Spravato Patient Brochure, Frequently Asked Questions, and Guide to Understanding Treatment-Resistant Depression all of which are included in the Welcome folder and available from your doctor.

Informed Consent: By signing below, I acknowledge that I have received information about the risks and benefits of Spravato treatment, and I consent to receive treatment with Spravato at Nepenthe Wellness Center / Peck Medical Services.