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Ibogaine Treatment
Medical Information
Drug & Medication Information
Information Usage & Privacy
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Salutation
Date of Birth
First Name
Last Name
Email
Home Phone
Mobile Phone
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.
Male
Female
Gender
Where do you live?
Address
ZIP/Postal Code
Do you have a current valid passport?
No
Yes
Suite #
State/Province
Do you have any pending legal issues?
No
Yes
City
Country/Region
If select YES describe legal issues (especially probation, federal charges, etc.)
Special Requirements
Do you have any special care requirements to be considered when attending the program?
If other, provide more details.
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