OM DIVINITY CHURCH MEDICAL INTAKE FORM - OM Divinity Ayahuasca Church

First Name *

Last Name *

Email Address *

Phone Number *

Street Address *

City

State/Province

Date of Birth *

Gender *

WELCOME OM

We are honored to support you in your self-discovery and healing journey. We take the health and safety of every guest who attends our retreat very seriously. Ayahuasca is generally safe but there are relevant health risks to certain health conditions. As such, we ask that you answer all questions in the following form honestly and thoroughly by truthfully disclosing any relevant personal information about your health. If there are any issues that might prevent you from safely attending a retreat with us, we will follow up with you, and in the event that a retreat with us is not a good fit, a full refund of your registration will be made.

Your registration is not complete until your medical questionnaire has been reviewed and approved by our staff and we have received your deposit.

Due to expenses incurred upon registration, OM Divinity Church is not able to offer refunds or discounts for late arrivals, leaving early, flight cancellations, travel delays, or illness. If you cancel your participation in the retreat for any reason, the cancellation policy below will apply without exception. While our mission is to extend compassion to our participants, please note, that there are incurred costs when your reservation is confirmed. Therefore, we are unable to accommodate refunds. We strongly encourage each participant to purchase travel insurance in the event unforeseen circumstances may arise.

IF YOU MUST CANCEL YOUR SCHEDULED RETREAT

You will be given a credit for ANY upcoming scheduled retreat. Because space is limited, we ask that you notify us as soon as possible of the date you would like to schedule so we can book your registration.

About Ayahuasca (Our Sacred Sacrament)

We are honored to support you in your self-discovery and healing journey. We take the health and safety of every guest who attends our retreat very seriously. Ayahuasca is generally safe but there are relevant health risks to certain health conditions. As such, we ask that you answer all questions in the following form honestly and thoroughly by truthfully disclosing any relevant personal information about your health. If there are any issues that might prevent you from safely attending a retreat with us, we will follow up with you, and in the event that a retreat with us is not a good fit, a full refund of your registration will be made.

What is the date of the retreat you are attending? *

Emergency Contact and Phone Number *

Have you done Ayahuasca before or any other psychedelic plant medicine? Please describe if yes* *

Is your emergency contact aware of your Ayahuasca Retreat?* *

Are you currently under the care of a family physician or any other health professional? If yes, please indicate Health professional's contact and condition treatment.

Please list any medications you take:

Please list any non-prescription medications you take:

Please list any supplements you currently take or have taken in recent past: Name supplement dosage and how long?

Please list your recreational habits. Please describe, when applicable.

Other, please describe below

Allergies

Do you have any allergies?YesNo

Do you have any food allergies?

Do you have any drug allergies?YesNo

Have you ever been diagnosed with the following conditions?

Please explain if you suffer from any mental illness (depression, bi-polar, schizophrenia, obsessive compulsive disorder, paranoia, suicidal tendencies, multiple personality disorder, chronic anxiety, PTSD, clinical depression, borderline personality disorder, chronic anxiety, self harming ect,)? *

Are you currently taking ANY anti-depressant medications OR supplements currently prescribed or self administered and the duration you have been taking them (including phenibut, psilocybin, cannabis, ketamine, ect.)? Please list the dosage and the length of time you have been taking them?

Please indicate the age of your first use and the age of your last use: (e.g. 16-22)

Do you use any recreational drugs? Which? *

I will discontinue all use of alcohol, marijuana, recreational/street drugs and non-prescribed pharmaceuticals at least one month prior to attending my plant medicine retreat. * I understand that many street and recreational drugs strongly contradict with Ayahuasca and can be very dangerous and potentially fatal when combined. (Please sign below)

Please describe what are your intentions of communing with Mother Ayahuasca. *

ATTESTATION: I have completed this questionnaire myself, have answered truthfully, and understand that withholding or misrepresenting any information could result in serious complications when drinking Ayahuasca and can be fatal. (Please sign below). *