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Full Intake Application

IBOGAwaken Full Intake Application 

Qualifying health assessment /disclosure statement, please take the time to fill out the information below.

We invite you to fill out our qualifying intake form, there are some contraindications when taking IBOGA and we need to understand your current health situation. Once we receive the submitted form we will contact you on your chosen time to discuss the next steps.

Please note: all fields are required if you do not have an answer please type N/A, thank you for taking this time to complete the required details.  

Are you seeking to resolve any of the following?
Do you have diabetes?
Do you drink alcohol?

A standard drink = 1 nip (30ml) spirits, 100ml wine, 10oz/285ml beer 

2 standard drinks = a pint (568 ml), a large glass of wine (200ml)

Do you take recreational drugs?
Have you had any surgeries with anesthesia in he last month?
Have you had any Corona Vaccination
Please select type (if not select N/A)
Please click what is applicable

By submitting you will also receive our IBOGAwaken Retreats newsletter that gives you quarterly updates on new retreats, locations, and everything new to  IBOGAwaken. Our newsletter aims at involving you in our world and the world of possibilities for you

Thanks for submitting!

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