Apply for Treatment | Experience Ibogaine Treatment Center

Personal Information
Name
First Last
Date of Birth
Date Format: YYYY slash MM slash DD
Where do you live?
City State / Province / Region ZIP / Postal Code Country
Height (specify cm or feet)
Weight (specify kg or lbs)
Email
Phone
Do you have a valid passport?
- Yes
- No
Do you have any pending legal issue?
- Yes
- No
Please describe this legal issue:
Information Disclosure

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 Name
First Last
Emergency Contact: Relationship to you
Emergency Contact Email
Emergency Contact Phone
Consent to Contact
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.
- 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.
Is the contact person the same as your emergency contact?
- Yes
- No
Contact Person Name
First Last
Contact Person: Relationship to you
Contact Person Email
Contact Person Phone

Unprescribed Substances

Substance	Method of Use	Dosage	Frequency of Use

Including illicit drugs and over the counter substances.

Prescribed Medication

Medication Name	Method of Use	Dosage	Frequency of Use

Supplements, Herbs, etc.

Name	Method of Use	Dosage	Frequency of Use

Please describe your history with addiction, past and present:
Do you have any prescribed medication that you ARE NOT currently taking?
- Yes
- No

Prescribed medication you are NOT currently taking

Medication name	Prescribed for	Dosage prescribed	Reason for not taking

Please describe any use of alcohol use:

Type of alcohol	Quantity	Frequency

If yes, please provide details:

Approximate date	Conditions treated

Procedure	Approximate Date

Personal Information