treatment-application

Email

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Patient's Full Name:(Required)

Phone(Required)

Email(Required)

Date of Birth:(Required)

Weight & Height(Required)

Have You Tried Ibogaine Treatment?(Required)

Emergency Contact Name:(Required)

Relationship:(Required)

Emergency Phone:(Required)

Date(Required)

Email(Required)

Medical Evaluation

Do you have any allergies?(Required)

Explain:(Required)

Pre-existing medical condition(s), surgeries/procedures:(Required)

Any special dietary considerations:(Required)

Please list all prescribed medication, drugs, or supplements you are currently taking, or have taken in the past six (6) months. Include dosage, frequency, method, and length of use:(Required)

Any history of cardiac problems/surgeries, diabetes, hypertension/high blood pressure?(Required)

Pre-existing mental health issue(s), including mood disorder(s):(Required)

Describe when:(Required)

Would you describe your past psychedelic experience(s) as positive or negative? Please explain(Required)

Have you ever had hallucinations or a psychotic episode, whether connected with psychedelics or not?(Required)

Do you have any history of a mental health diagnosis, psychiatric admissions, suicidal ideations/attempts?(Required)

Are there any relatives who have a history of mental health issues, including psychiatric admissions and suicidal ideations/attempts?(Required)

Have you ever experienced paranoia, or a nervous breakdown due to stress or burnout?(Required)

Are you seeking to resolve any history of belligerent or assaultive behaviour, whether under the influence or not?(Required)

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Treatment Application

(619) 815 5181

info@newpathibogaine.com