Application for Ibogaine Therapy Array

Please answer all questions as accurately as possible, paying special attention to medical and substance use profiles. Incomplete or false information can lead to unintended consequences that may greatly effect your treatment and may lead to serious harm. Keep in mind that most, if not all, of the Ibogaine related complications or deaths have occurred because of heart problems, inaccurate reporting of substance use, and/or use of opiates during or just after treatment. Thank you for your honesty.

A printer-friendly PDF version of this form is also available on our document download page, accessible here.

Please fill out all questions that pertain to your treatment.Current Date: Friday, July 19th, 2019
 
* : * :
* : * : * : *Height:
* :    * : * :    * :
* :    * : *:    * :
* : * :    :
: :
: :

* :
* : Yes No
:
* : Yes No
:
* : Yes No
:
* : Yes No
* : Yes No
:
* : Yes No
:
* : Yes No
:
* : Yes No
:
:
:
:
: Yes No
:
:
: Yes No
:
:
:
:
* :
* : Yes No
Check All That Apply:  
:
:
:
:
:
:
:
* : Yes No
Check All That Apply:  
 
:
:
: Yes No
:
:
:
: Yes No
:
:
:
: Yes No
: Yes No
: Yes No
: Yes No
: Yes No

Information Usage & Privacy Policy

Your personal information will be held in the strictest of confidence. We do, however, ask that you allow us to use the information you have provided and any data gathered during your treatmentfor research purposes. None of your personal information will be associated with this data. Any information that can be added to the growing knowledge base for ibogaine therapy will lead one step closer to the legitimization and legalization of this very important medicine. Thank you!
* : Yes No
NOTE: Indicating a, 'No,' answer to this question will not preclude you from receiving Ibogaine therapy.