IBOGAINE TREATMENT APPLICATION

Information usage and privacy policy

Your personal information will be held in the strictest of confidence. We do however ask that you allow us to use the information you have provide and any data gathered during your treatment for research purposes. None of the personal information will be associated this data. Any information that can be added to the growing knowledge based for ibogaine therapy will lead us one step closer to the legitimization and legalization of this very important medicine. Thank you!

 

NOTE: indicating a NO answer to this question will not preclude you from receiving ibogaine therapy.

MEDICAL INFORMATION FOR IBOGAINE TREATMENT

Medical questionnaire

List all medications you are currently taking, include over-the-counter drugs and herbal supplements:

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