1 (800) 644-8482
aeden@experienceibogaine.com

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1 (800) 644-8482
aeden@experienceibogaine.com

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Application

Step 1 of 10 - Contact Information

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To ensure that I am a safe and appropriate candidate for treatment, I confirm that all information provided in this form is accurate and complete. I acknowledge that this information is true and correct to the best of my knowledge and is provided for my own safety.

Full Name(Required)

First Last

Email(Required)

Phone Number(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Use a permanent address where you can receive mail.

Please list weight and height in imperial units (Pounds/Lbs & Feet)

Height(Required)

Weight(Required)

Age(Required)

Please enter a number from 1 to 100.

Date of Birth(Required)

MM slash DD slash YYYY

Are you a veteran or first responder? (LEO, firefighter, paramedic, EMT, ER Doctor)(Required)

Yes

If you are a veteran or a first responder, please specify.(Required)

Do you have a valid passport or REAL ID.(Required)

Yes

Do you have any pending legal issues such as warrants, pre-trial probation, ongoing criminal cases, probation, or parole? This can potentially prevent you from leaving your state or the country.(Required)

Yes

Experience Ibogaine requires that you provide us with an emergency contact person. This person will only be contacted in case of emergency, and otherwise no information regarding your treatment will be disclosed.

Emergency Contact's Full Name(Required)

First Last

Emergency Contact's Email(Required)

Emergency Contact's Phone Number(Required)

Relation to Patient(Required)

Experience Ibogaine takes every measure to keep your personal and medical information confidential. In many cases it is desirable for a family member or other loved one to receive updates about the status of your treatment, as well as to be informed about options for continuing care. In order to provide any information, outside of an emergency situation, we require your consent.

CONSENT TO CONTACT(Required)

I CONSENT FOR EXPERIENCE IBOGAINE TO CONTACT A FAMILY MEMBER OF LOVED ONE AND TO DISCUSS ASPECTS OF MY TREATMENT, MY MEDICAL RECORDS, AND MY OPTIONS FOR CONTINUING CARE EVEN OUTSIDE OF EMERGENCY SITUATIONS

Substance Addiction Information

For reasons of safety, It is crucial to list every substance, as certain protocols are required. If the the pre-treatment protocol is not followed upon arrival, patients are subject to disqualifications. Each patient must pass a urine screening upon arrival. If scheduling allows for it, patients may be able to extend their stay to a detox program for an additional cost. This includes substances, within the past 90 days.

Substance Information(Required)

substance?

method?

dosage?

frequency?

Substance Information (Within Past 90 Days)(Required)

substance?

method?

dosage?

frequency?

How long have you been taking each substance?(Required)

Prescription and Over-the-Counter Medication

For your safety, it is critical that you fully and accurately disclose all medications you are currently taking. Certain medications must be completely out of your system before ibogaine treatment can begin. Failure to provide complete and accurate information may not only delay your ability to proceed with treatment, but also increase the risk of serious health complications or disqualifications. This includes medications, and medications not taken, within the past 60 days.

Medication Information(Required)

medication?

method?

dosage?

frequency?

Medication Information (Past 60 Days)(Required)

medication?

method?

dosage?

frequency?

How long have you been taking each medication?(Required)

What was the reason for being prescribed(Required)

Are there any prescribed medications you're not taking?(Required)

Yes

List the prescribed medication you are not taking(Required)

When was the last time you took these medications(Required)

What was the reason for being prescribed?(Required)

Vitamins, Nutrition & Herbal Supplements

For your safety, it is critical that you fully and accurately disclose all supplements you are currently taking. Certain supplements must be completely out of your system before ibogaine treatment can begin. Failure to provide complete and accurate information may not only delay your ability to proceed with treatment, but also increase the risk of serious health complications or disqualifications. This includes supplements, within the past 60 days.

Supplement & Herbs Information(Required)

supplement?

method?

dosage?

frequency?

Supplement & Herbs Information (Past 60 Days)(Required)

supplement?

method?

dosage?

frequency?

How long have you been taking each supplement?(Required)

Why are they taking each supplement?(Required)

Were they instructed by a nutritionist or Doctor?(Required)

Are you currently taking buprenorphine? (Suboxone, Subutex, Zubsolv, Sublocade)(Required)

Yes

How many milligrams of buprenorphine (Suboxone, Subutex, Zubsolv, Sublocade) are you taking?(Required)

How long have you consecutively taken buprenorphine?(Required)

Are you currently taking methadone?(Required)

Yes

How many milligrams of methadone are you taking?(Required)

How long have you consecutively taken methadone?(Required)

Alcohol Use(Required)

Please list all types and quantities of alcohol you consume(Required)

Type?

Quantity?

How long have you been drinking?(Required)

Can you discontinue alcohol for more than 14 days at a time?(Required)

Yes

Do you consume tobacco or use nicotine vaporizer?(Required)

Yes

Medication Notification Requirement

To ensure safe and effective treatment, it is essential that Experience Ibogaine has complete and accurate information about your medical history. Withholding details about supplements, prescriptions, over-the-counter medications, or alcohol may prevent us from providing treatment. Any additional medications, supplements, prescriptions, or alcohol consumed after submitting this application but before beginning treatment must be reported to our team, as these changes could impact your health and care plan. Arriving for treatment without notifying us of such changes may result in disqualification from receiving treatment upon arrival. All patients are also required to pass a urine screening upon arrival.(Required)

By Clicking 'Yes' below, I confirm that I have read, understood, and agreed to these terms.

Addiction History(Required)

Family History of Medical Conditions(Required)

Please elaborate on treatments and outcomes of each condition(Required)

Please List Any Allergies to Food or Medications(Required)

Medication Or Food?

Reaction?

Please List Any Surgeries(Required)

Procedure?

Date?

Have you been diagnosed with any diseases?(Required)

Yes

What disease(s) have you been diagnosed with?(Required)

Has it been successfully treated?(Required)

Do you take medication for it?(Required)

Do you have thyroid or hormonal issues?(Required)

Yes

Is your thyroid or hormonal issues under control?(Required)

Are you taking any medication for your thyroid or hormonal issues and what medication are you taking?(Required)

Do you have hypertension or hypotension?(Required)

Yes

Do you have your hypertention/hypotension controlled with medication? If so, what medication?(Required)

Do you get dizzy or faint when standing up?(Required)

Yes

Do you have a vascular disease including aneurysms?(Required)

Yes

Have you experienced embolism or blood clotting or recent trauma to the body?(Required)

Yes

Have you ever had a stroke?(Required)

Yes

If yes, can you please elaborate regarding your vascular disease, aneurysm, embolism.(Required)

Have you received treatment for vascular disease, aneurysm, embolism, blood clotting.(Required)

Have you ever had heart murmurs, bradycardia, tachycardia, arrythmias, blockages, myocardial infarctions (Heart attack) or any other cardiac-related conditions?(Required)

Yes

What cardiac conditions do you have diagnosed and how recent was your diagnosis?(Required)

Have you ever had any calcium, magnesium, or potassium deficiencies?(Required)

Diabetes? If yes please bring your insulin.(Required)

Yes

Hypoglycemia?(Required)

Yes

If yes, is it under control?(Required)

Have you had any recent bodily trauma?(Required)

Yes

If yes, please elaborate(Required)

Have you experienced any type of brain injury?(Required)

Yes

What was the diagnosis of your brain injury?(Required)

Have you had a CT scan, MRI, or any other type of brain scan?(Required)

Yes

If yes, please elaborate on scan & results(Required)

Have you experienced any brain bleeding, lesions, cranial damage, or shrapnel?(Required)

Yes

Have you experienced any type of brain seizure?(Required)

Yes

what type of seizure(s) have you experienced and what was your diagnosis?(Required)

Was the seizure related to substances and/or substance withdrawal(Required)

Are you currently taking medication to treat your seizures?(Required)

How frequently do you experience seizures and when was the last time you had an episode?(Required)

Surgery of gastrointestinal tract or disease including ulcerative colitis, crohn's disease, bleeding or peptic ulcer?(Required)

Yes

If yes, which condition have you been treated for and was the treatment successful?(Required)

Have you been diagnosed with hepititis B or C, Including Abnormal Liver Function - Primary Biliary Cirrhosis, Elevated Serum Ammonia Levels - Etc?(Required)

Yes

If yes, which condition have you been treated for and was the treatment successful?(Required)

have you ever had elevated or decreased levels of liver enzymes such as Alanine transaminase (ALT) Aspartate transaminase (AST) Alkaline phosphatase (ALP) Gamma-glutamyl transferase (GGT) Total protein?(Required)

Yes

Please send us your most recent lab work(Required)

Have you ever had any type of kidney function issues?(Required)

Yes

If yes please elaborate

Have you ever excreted dark, brown urine, or bloody urine?(Required)

Yes

If yes, when was the last time?(Required)

Have you ever had any high or low levels of creatinine?(Required)

Yes

Do you get nauseous easily?(Required)

Yes

Have you ever coughed, vomited, urinated, or defecated blood?(Required)

Yes

Why and when was the last time you have coughed, vomited, urinated, or defecated blood?(Required)

Do you have insomnia?(Required)

Yes

If yes, on a scale of 1 - 10. (10 being worst & 1 being ideal)(Required)

Are you asthmatic? If yes please bring your inhaler(Required)

Yes

Do you have sleep apnea? If yes, please bring your CPAP or sleep aid machine.(Required)

Yes

Are your veins in good condition?(Required)

Yes

Will you need to have central line if no vein access? (If yes, a $500 USD fee will be charged if we can't find vein access)(Required)

Yes

Do you consider yourself depressed?(Required)

Yes

Have you ever tried to commit suicide?(Required)

Yes

Reason for suicide attempt?(Required)

Have you ever been admitted to psychiatric hospital?(Required)

Yes

Reason for being admitted to psychiatric hospital & how long was your stay?(Required)

Have you been diagnosed at the psychiatric hospital?(Required)

Did you receive any medication at the psychiatric hospital? If yes what medication(s)(Required)

If yes how did they help you?(Required)

Have you been diagnosed with a psychiatric condition by a professional outside of a psychiatric hospital?(Required)

Yes

If yes, what were you diagnosed with?(Required)

If you have been prescribed any medications what kind?(Required)

Can you elaborate on how they can help you?(Required)

If you take the medications do they help?(Required)

Do you have any recent type of skin lesions?(Required)

I have skin lesions and I HAVE taken antibiotics in the last month.

I have skin lesions and I HAVE NOT taken antibiotics in the last month.

Is the skin lesions still infected?(Required)

Yes

Do you have mistrust in people?(Required)

Yes

Why do you mistrust people?(Required)

Have you traveled to Tijuana before?(Required)

Yes

What was the purpose of your trip to Tijuana?(Required)

Have you ever had a bad time with a psychedelic substance?(Required)

Yes

Please explain what took place during your bad experience.(Required)

Elaborate on which psychedelic, what was the dose, and what was the setting like(Required)

Have you committed to an aftercare plan?(Required)

Yes

What is your aftercare plan?(Required)

Please select all medical conditions that you currently or previously have had(Required)

None

Asthma

Back Problems

Bleeding

Cancer

Constipation

Diabetes

Excessive Menstruation

Heartburn

Heart Problems

High Blood Pressure

History Of Ulcers

HIV/AIDs

Jaundice

Joint Pain

Loss Of Menstruation

Low Blood Pressure

Muscle

Nausea

Nerve Damage

Painful Menstruation

Paranoia

Shaking

Shortness Of Breath

Spasms

Stomach

Stroke

Swelling

Thyroid Problems

Tuberculosis

Urinary Problems

Varicose Veins

What makes you paranoid(Required)

Additional notes or anything you would like to add.

Declaration of Accuracy and Consent to International Data Transfer(Required)

By Clicking 'Yes' below, I confirm that I have read, understood, and agreed to these terms.

1. Representations and Warranties of Accuracy I hereby represent and warrant that all information, data, and records I have submitted to Experience Ibogaine Treatment Center are true, accurate, current, and complete. I assume full legal and personal responsibility for the validity and integrity of this information and acknowledge that upon reviewal, the team of medical professionals relies heavily upon its accuracy to provide safe and appropriate care. 2. Acknowledgment of Confidentiality I acknowledge that my Sensitive Personal Data and Protected Health Information (PHI) will be maintained in accordance with applicable confidentiality and security protocols as well as in compliance with local and federal laws. I understand that these records are protected to ensure my privacy and safety. 3. Explicit Consent for International Data Transfer For the explicit purpose of qualifying for admission and treatment at the Facility, and to ensure my personal safety during such treatment, I hereby grant my voluntary and informed consent for the international transfer of my Personal Data and Medical/Health Data. Specifically, I authorize the transmission of this data from the United States of America to Mexico. I acknowledge and agree that this transfer shall be facilitated by and between the following entities: Experience Life Sciences (United States) and Serenity Now (Mexico)

Begin Your Journey to Recovery

Start your journey towards recovery with our proven ibogaine therapy. Our dedicated team is here to support you every step of the way.

Schedule a Free Consultation

Experience Ibogaine Treatment Center

At the heart of our mission is a deep compassion for those we serve. We understand the journey to recovery is personal and profound.

Treatments

Alcohol Addiction
Anxiety & Depression
Cocaine Addiction
Drug Addiction
Fentanyl Addiction
Heroin Addiction
Pain Management
Methadone Addiction
Methamphetamine Addiction
Opioid Addiction
PTSD
Suboxone and Buprenorphine Addiction
Traumatic Brain Injury
Hydrochloride Treatment

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P.º Ensenada 1317-6, Playas de Tijuana, Jardines Playas de Tijuana, 22505 Tijuana, B.C., Mexico

aeden@experienceibogaine.com

1 (800) 644-8482