Spravato Patient Driver / Transportation Form

SPRAVATO® PATIENT DRIVER / TRANSPORTATION FORM

Patient Name

Date of Birth

Driver Information

Driver Name

Relationship to Patient

Transportation Confirmation

I understand that the patient is receiving SPRAVATO® (esketamine) and may experience sedation, dizziness, impaired attention, judgment, coordination, or other effects following treatment.

I confirm that I will:

Patient Acknowledgment

I understand that I must arrange transportation with a responsible driver following each SPRAVATO® treatment. I understand that I am not permitted to drive myself home after treatment, even if I feel well enough to drive.

Patient Signature

Date