IbogaQuest Application

To start your screening process with us, please complete the application below, either in its entirety or in part, as appropriate. It is a guideline regarding the information which may be relevant to a safe and meaningful Ibogaine experience.

Please answer the questions as accurately as possible, paying special attention to medical and substance use profiles. Thank you for your candor.

Fields marked with an * are required fields.

Payment

In order to schedule and reserve your space, you will need to send a 20% deposit. Balance of your payment needs to be received when you arrive here in cash and in full before starting treatment.

Please contact us for more information about prices which are, of course, subjective, depending on your situation and requirements.

For more information:
Email info@ibogaquest.com or
Call US 802-748-4600, MEX 01-739-395-0780

General Information:
* Full Name:
* Gender:	Male Female
* Age:
* Weight:
* Height:
* City:
* State/Province:
* Country:
* Primary Phone:
Cell or Other Phone:
* Email:
Emergency Contact Information:
* Emergency Contact:
* Relation To You:
* Their Primary Phone:
Their Cell or Other Phone:
Doctor's Full Name:
Doctor's Phone:
Psychiatrist/Therapist Full Name:
Primary Phone:
Household Info:
Married/Single/Children?:
Living Situation: i.e. Apartment, Homeowner, Alone, Roommate, etc.
Occupation/Employment Status:
About You:
* Reason for wanting Ibogaine Therapy:
* Have you ever used Ibogaine?	Yes No
If yes, when, where, and why?
* Do you have any allergies?	Yes No
If yes, please explain allergies:
* Do you have any specific dietary needs (vegan, diabetic, etc.)?	Yes No
If yes, please explain:
* Do you have experience with psychedelics or visionary plant medicines?	Yes No
If yes, please explain:
* Do you have a valid passport?	Yes No
* Do you have any pending legal issues?	Yes No
If yes, please explain:
* Do you smoke?	Yes No
If yes, how much and how often do you smoke?
* Do you drink alcohol?	Yes No
If yes, how much and how often?
* Are you currently using any PRESCRIPTION or NON-PRESCRIPTION substances?
	Yes No
List NON-PRESCRIPTION* substances used, how much, and how often? If you answered No above, please put n/a
List PRESCRIPTION* medications you are taking. Show daily dosage, for what & how long? If you answered No above, please put n/a
* Are you suffering from any emotional or mental conditions?	Yes No
Check All That Apply:	Bi-Polar Schizophrenia Depression PTSD Obsessive/Compulsive Eating Disorder Other
Please expand upon or explain items checked above:
List history and treatment for any of these conditions:
How do you handle emotional experiences:
How would you characterize your overall physical condition:
When was the last time you saw a doctor?:
For what reason?:
* Do you have any physical conditions or illness?
Yes No
Check All That Apply, including family history:
Diabetes Stroke Hepatitis A, B, or C Headaches Bleeding Abdominal pain Stomach problems History of ulcers Liver problems Slow heart rate History of seizure Jaundice Urinary problems Thyroid problems Heart problems Heart disease Low blood pressure Respiratory problems Asthma Loss of menstruation Painful menstruation Excessive menstruation Cancer Swelling Fainting Joint pain Numbness Varicose veins Diarrhea Back problems HIV positive / AIDS Nausea Shaking Dizzy spells Tuberculosis High blood pressure Shortness of breath Renal disease Muscle spasm Nerve damage Heartburn Constipation Obesity
Please list any recent(10 years) surgeries and dates:
When would you like to come for treatment?
Comments: Is there anything else you'd like to mention?
How did you hear about us? Please include name of person or friend that referred you.

IbogaQuest Application

General Information:

Emergency Contact Information:

Household Info:

About You:

Payment