The Medicine Angel –
Screening Questionnaire

Please, fill up the form below and send it to go further with your booking

1. Is this the first time Ayahuasca plant medicine experience for you?
2. Are you currently taking any medications? If so, please name them, the dosage, frequency and how long you have been on the medication(s).
3. Have you been taking any antidepressants within the last 40 days? If so, please name them, the dosage, frequency and how long you have been on the medication(s).
4. Do you have any history of heart related concerns? ie, hypertension (High Blood Pressure, Arrhythmia, Tachycardia, Heart attacks, Heart surgery, stents, shunts etc.
5. Have you ever experienced a seizure, stroke or been diagnosed as epileptic or diabetic?
6. Do you or anyone in your immediate family (parents or siblings) have schizophrenia or Bipolar disorder?
7. Do you have any complimentary spiritual practices that you enjoy, ie yoga, meditation, chi gung, tai chi etc.? Do you practice any form of energy healing, ie Reiki, Pranic Healing etc.?
I acknowledge that the entire healing process that I consent to, is done at my own risk and no one can be held responsible for it, apart from myself as I am doing it voluntarily.

Once you have sent your medical questionnaire abode, click here to continue to booking