Thank you for your interest in our Ayahuasca Ceremonies. Please fill out this form prior to your ceremony. Name * First Name Last Name Email Age * Gender * Male Female Other How did you find us? * Will this be your first experience with Ayahuasca? If not, please explain your experience. * Health History * Do you suffer from any of the following health issues? (Past or current) Heart Disease/Condition (Can't tolerate exercise) Liver Failure Kidney Failure High Blood Pressure Psychotic Episodes (not drug related) Schizophrenia Epilepsy Bipolar Disorder Pregnancy Diabetes None of the above Do you have any direct family history of the following? * Schizophrenia BiPolar Disorder Epilepsy Are you on any prescribed medications or supplements? Please list here and your reason for taking them. * As Ayahuasca is an MAOI inhibitor (monoamine oxidase inhibitor) it can interact with many different types of medications. Do you have any serious allergies to medications or foods? * Thank you! We look forward to facilitating and creating an amazing experience for you.Obrigado! Estamos ansiosos para facilitar e criar uma experiência incrível para você.Mara+(714) 488-2219+55 (22) 99720-0472
