Please enable JavaScript in your browser to complete this form.Name *FirstLastGender *MaleFemalePrefer not to sayEmail *Mobile number with country code * other frequency retreat Date of birth *Arrival date at the retreat (please, remember retreats starts on Mondays, so this date must coincide with any Monday of the year) *Emergency contact information *Have you had any injuries or accidents? *Have you participated in an Ayahuasca Ceremony in the past? *Do you follow a specific diet? *Do you have any of the following:AllergiesAsthmaClaustrophobiaDepressionDiabetesEpilepsyHeart diseaseHigh blood pressureBlood disorderBipolar disorder / schizophreniaBeside of the above, do you take any medication or tablets? *Did/do you consume any type of drug? *Do you drink alcohol? *YesNoIf yes, please mention an average quantity and frequencyTerms and conditions: By submitting this form, I certify that the information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. I certify that by the time of the retreat I will not have consumed any recreational drugs for a month, nor prescription for anxiety/depression/sleep for 2 weeks or any other undisclosed medicines. I understand that failure to do this implies to put my health at serious risk. *I agreeSubmit
