300 Office Park Dr Suite 105

Mountain Brook, AL 35223

205-848-2768

8 am-4 pm, Monday-Friday

Patient Forms

Welcome to Crestline Health and Wellness

Ketamine therapy treatments offer relief for many patients and may provide relief for you. We recognize that choosing to move forward with these treatments can be challenging and requires a significant commitment. We look forward to working with you as partners in your care. Please contact us at any time with questions, or with comments, or for more information. Sincerely, Dr. Amy van Elkan mail@crestlinehealthandwellness.com 205-848-2768 To register as a new patient please complete and submit the forms in this packet:
  •    General Information – 2 pages
  •    Medical History – 2 pages
  •    Consents and Authorizations – 2 pages
  •    General Policies – 2 pages
  •    Notice of Privacy Practices – 3 pages
  •    Physician Referral – 1 page
If you are being treated for a mood disorder, our minimum requirement is that patients have, and list in their paperwork, a psychiatric professional who they can rely upon for their psychiatric needs. To submit the completed forms or you may bring with you to your consultation: Mail:
Crestline Health and Wellness
300 Office Park Drive, Suite 105
Mountain Brook, Alabama 35223
Or email: mail@crestlinehealthandwellness.com Scheduling your treatment: Contact us at any time to schedule your treatments.
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