Name
*
First Name
Last Name
Email
*
Date of Birth
*
MM
DD
YYYY
Phone
*
(Whatsapp)
Country
(###)
###
####
Did you have a ceremony before? How many times? When was last? How many points?
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Tell me about your physical health?
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What is the story of your mental health? Do you have phobias, which ones?
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What drugs, medications, dietary supplements do you take? (prescription and over-the-counter) SPECIFY ALL TITLES
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Have you ever had heart problems, strokes?
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Have you had any operations? If so, which ones and when?
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Have you ever taken psychoactive substances, alcohol, recreational drugs, or other herbal or animal medicine (Bufo, Iboga)? What and when were the last times?
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Have you recently/permanently done any fasting, detoxes, enemas, liver cleansing or other cleansing procedures?
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Can you be pregnant?
Do you breast-feed a baby up to 6 months?
Confirm that you are aware of the list of contraindications
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Is there anything else that is important for me to know about your health?
Estimated date of the ceremony?
Notice
*
Data Protection Copy
*
What is 11 +4 ?
*
