Now accepting Telehealth appointments. Schedule a virtual visit.

New Patient Forms


 

Downloadable

These forms are required for all Lidocaine and Ketamine infusions. Nutritional infusions only require the first two forms.

All forms can be clicked on, downloaded, and filled out online. 

To expedite things, it is preferable if you email or fax these forms back to us. If that is not possible, you may bring them to your first visit.

Intake Form

Medical History Form

Medical Records Release Form

Provider Referral Form

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Location
Pacific KLN Infusions
106 South Grape Street, Suite 12
Escondido, CA 92025
Phone: 909-328-8948
Fax: (888) 398-0946
Office Hours

Get in touch

909-328-8948