Ibogaine Treatment Facilities For US Cities

Name(Required)

First Last

Email(Required)

Phone Number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Use a permanent address where you can receive mail.

Height(Required)

Weight(Required)

Age(Required)

Please enter a number from 1 to 100.

Date of Birth(Required)

Do you have a valid passport?(Required)

Yes

No

Do you have a pending legal issue?(Required)

Yes

No

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.

Name(Required)

First Last

Email(Required)

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 Use Information

substance?

method?

dosage?

frequency?

Medication Information

medication?

method?

dosage?

frequency?

Supplement & Herbs Information

supplement?

method?

dosage?

frequency?

Addiction History(Required)

Family History of Medical Conditions(Required)

Any Prescribed Medication You Are Not Taking?

Yes

No

Do You Consume Tobacco Or Use Nicotine Vaporizer?

Yes

No

Alcohol Use

Please List All Types and Quantities of Alcohol You Consume

Type?

Quantity?

Please List Any Allergies to Food or Medications

Medication Or Food?

Reaction?

Please List Any Surgeries

Procedure?

Date?

City

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