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Medical History Form

Your details are confidential Information. Plant & Animal ceremonies are intended to be a personal growth experience and should not be considered a substitute for psychotherapy, but rather a complementary therapeutic device. Working with Mushrooms, Ayahuasca or Bufo Alvarius can involve intense experiences accompanied by strong emotional and physical releases. It is not recommended for people with cardiovascular problems, serious hypertension, psychiatric conditions, recent fractures or surgery, acute infectious diseases, epilepsy or pregnant women. Please answer all questions as fully as possible. Your answers are intended to help facilitators and are strictly confidential.

If you have answered ‘yes’ to any of the questions above, it is important to give specific details by emailing [email protected] to set up a phone call with facilitators. We cannot confirm your place at the session until we have received this form. Please read and sign the following declaration.

Medical History Form
Medical Name
Medical Name
First
Last
Do you currently suffer from or have a family history of any of these ailments?
Please read and check all the following declarations.

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