Medical Form

Please indicate which retreat you are interested in joining *

Name *

First

Last

Email *

Email

Confirm Email

Country of Residence *

Province / State *

Phone no.: *

Gender *

Male
Female

Age *

Any food requirements? *

Please add any food allergies/requirements in addition to those noted above:

Profession

Emergency Contact Information: Name/Relationship/Email/Phone *

Please let us know how you heard about this retreat *

Please share a little bit about your personal journey and reasons why you feel called to come work with ayahausca *

Please share any previous experience you may have had in working with plant medicines. *

Please describe any concerns you may have regarding your participation in an Amazonian plant medicine ceremony. *

Do you have a past history of, or currently suffer from any serious health conditions ? *

The traditional Shipibo amazonian medicine ceremony is rooted in the ancient practice of finding the cure. The intention is to bring the body back into its whole state. This is one of the oldest forms of shamanism, the Shipibo tradition itself is one of the oldest existing in the amazon. Participation in the ceremonies can involve dramatic experiences accompanied by strong emotional and physical release. This ceremony is not appropriate for persons with certain medical conditions or for persons using certain medications. Please answer the following questions as completely and honestly as possible. Your responses will remain strictly confidential.

Have you ever been hospitalized for medical reasons? (Please elaborate) *

Have you ever been hospitalized for psychiatric reasons? (Please elaborate) *

Are you currently taking any type of medications? If yes, please list the medications dosage and frequency taken. Please note that it is imperative that you list all medications, as the plant medicine can interact with certain medications in a way that can be dangerous. *

Have you ever taken SSRI medication for depression? If so when? For how long? *

List any medications that you have taken in the past 12 months. (Prescribed or over the counter) Please include dosage and frequency taken. *

Do you have any history of depression, anxiety, psychosis, bipolar illness or ADHD? *Please note that ceremonies should not be seen nor are they designed as a substitute for psychiatric or other medical care. *

Consent: I the undersigned hereby seek to participate in a traditional Shipibo Amazonian medicine ceremony. I agree to complete the Confidential Medical history form provided. I am assured that the information provided will remain strictly confidential and will serve only as a guide in determining the appropriateness of my participation in the ceremony and in meeting my needs before, during and after the ceremony. *

Yes

Confirmation: I hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly and have not withheld any information. My general health, as far as I am aware, is good. *

Yes

Invitation: Please add me to your mailing list for upcoming retreats *

Yes
No

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Today's Date

Medical Form

We look forward to being with you on retreat !

Please take the time to complete this form. It is the first step to register for any of our retreats.

Fields marked with an are required.*

Join Our Community

Beautiful Success !

earthtempleretreats

Medical Form

We look forward to being with you on retreat !

Please take the time to complete this form. It is the first step to register for any of our retreats.

Fields marked with an * are required.

Join Our Community

Beautiful Success !

earthtempleretreats

Fields marked with an are required.*