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Ibogaine Treatment
Medical Information
Drug & Medication Information
Information Usage & Privacy
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Salutation
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Date of Birth
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First Name
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Last Name
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Email
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Home Phone
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Mobile Phone
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What is your biological sex? Why we ask this question: Your biological sex at birth affects a) how your body metabolizes ibogaine, and b) pregnancy risk, which we screen for to ensure treatment safety. If you have questions about gender identity, group placement, or if there is any information you’d like us to know about you in this regard, you are welcome to discuss it with our team during your Intake call.
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Male
Female
Gender
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Where do you live?
Address
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ZIP/Postal Code
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Do you have a current valid passport?
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No
Yes
Suite #
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State/Province
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Do you have any pending legal issues?
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No
Yes
City
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Country/Region
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If select YES describe legal issues (especially probation, federal charges, etc.)
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Special Requirements
Do you have any special care requirements to be considered when attending the program?
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If other, provide more details.
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