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Ibogaine Treatment
Medical Information
Drug & Medication Information
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Salutation
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Date of Birth
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First Name
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Last Name
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Email
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Home Phone
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Mobile Phone
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What is your sex? (Why we ask this - this questin isn't about politics or gender identity. We ask for your biological sex at birth because it affects (a) how your body metabolizes Ibogaine and (b) pregnancy risk which we screen for to ensure treatment safety.) If you have questions about gender identify or group placement, or if there is anything additional you would like us to know, you are welcome to speak to our intake team.
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Male
Female
Gender
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WHERE DO YOU LIVE?
Address
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ZIP/Postal Code
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Do you have a current valid passport?
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No
Yes
Suite #
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State/Province
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Do you have any pending legal issues?
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No
Yes
City
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Country/Region
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If select YES describe legal issues (especially probation, federal charges, etc.)
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SPECIAL REQUIREMENTS
Do you have any special care requirements to be considered when attending the program?
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If other, provide more details.
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