Treatment Application

Personal Information
Full Name*
Birthday*
Where do you live?*
City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Phone*
Do you have a valid passport?*
- Yes
- No
Do you have a valid government issued photo ID and a birth certificate?*
- Yes
- No
Do you have any pending legal issues?*
- Yes
- No
Have you done ibogaine or iboga in the past, if so, how long ago?*
Have you tried any other psychedelics?*
How did you hear about us?*
Emergency Contact
Emergency Contact Full Name*
Emergency Contact Email*
Emergency Contact Phone*
Emergency Contact Phone*

Substance Use
Do you smoke tobacco?*
- Yes
- No
How much do you smoke per day?*
Do you drink alcohol?*
- Yes
- No
Please describe how much you drink per day/week/or month:*
Do you take any other drugs or medications of any kind?*
- Yes
- No
Please list all of them here:*
Drug/Medication Dosage Reason
Do you take any neutriceutical or herbal supplements?*
- Yes
- No
Please list all of them here:*
Supplement Dosage Reason
Information usage and 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 provide and any data gathered during your treatment for research purposes. None of the personal information will be associated this data. Any information that can be added to the growing knowledge based for ibogaine therapy will lead us one step closer to the legitimization and legalization of this very important medicine. Thank you!

NOTE: indicating a "No" answer to this question will not preclude you from receiving ibogaine therapy.
I agree to allow this information be used to further our knowledge of ibogaine therapy.

Personal Information

Drug/Medication	Dosage	Reason

Supplement	Dosage	Reason