Iboga Revolution | Online Application

Medical conditions we should be aware of:

Why are you seeking ibogaine?

Physical activities you engage in regularly and how many times per week:

List any prescription medications you are currently taking:

List any prescription medications you have taken in the last year:

List any over the counter medications you are currently taking:

List any over the counter medications you have taken in the last year:

Do you have a history of addiction? If yes, list substances and time of use:

Have you been through detox or rehab? Provide a brief explanation. Include dates

List any other drugs you have taken in the last year for spiritual or recreational purposes

Do you smoke cigarettes and if so how much?

Have you ever been diagnosed with any medical conditions? If yes, please list

When is the last time you had a check-up with a physician?

Do you have any previous experience with iboga? If yes, please explain where and when:

Have you ever been diagnosed with a psychological condition? If yes, please explain:

If yes, how many days a week do you drink?

One the days that you drink, how many drink do you normally have?

Have you ever been hospitalized for a medical or psychological condition?

Is there anything else we should know?

How did you hear about us?

Please list alternate dates in order of preference:

**Please note that we are unable to accept applications for detox or treatment of addiction.