Contact 2 — Lunaire

The Application

Congrats on answering the call to Iboga.

Please answer the below questions to determine eligibility and contact Maryam, who will be in touch, if this treatment is right for you.

Name

First Name

Last Name

Phone

(###)

###

####

Please list all medications, recreational substances, and supplements you have taken in the last 3 months:

Please check if you have any of these physical issues:

Asthma

Heart conditions (i.e arrhythmia..)

Liver and/or Kidney conditions

Neurological (history of seizures, schizophrenia..)

Why are you interested in iboga? Why now?

Are you committed to halting all substances, psychedelics and medicines, for six months after your treatment?

Yes