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    Ibogaine Treatment Application Form

In order to participate or enquire about ibogaine treatment /iboga ceremony please fill out an application form by either:

  1. Download Word Document, fill out and send to: info@ibogainetreatment.eu
  2. Download PDF Document, print, fill out by hand and send scan or quality picture to: info@ibogainetreatment.eu
  3. Fill out the form below and click “submit”

First Name (required)

Surname (required)

Mobile (required)

Email (required)

Address (required)

Country (required)

Emergency Contact - First Name (required)

Emergency Contact - Surname (required)

Emergency Contact - Mobile (required)

Emergency Contact - Email (required)

Gender (required)

Age (required)

Height (required)

Weight (required)

How did you hear about us?

I am seeking treatment for: (required)

In case of substance addiction treatment - What substance(s) are you seeking detoxification from?:

In case of substance addiction treatment - Have you ever been abstinent from the substance(s) you are seeking to detoxify from?:

In case of substance addiction treatment - Please provide a detailed chronological history of your substance use. (For example: 2003 - 2007 - 80mg of methadone one a day a day):

In case of substance addiction treatment - Please list other detox or treatment programs you have participated in, and tell us why they did or didn't work for you:

Date Requested

Please provide a list of all medications you are prescribed, and are currently taking

Please provide a list of all medications you are prescribed, but are NOT currently taking

Please list all supplements, nutraceuticals or performance enhancers you’ve taken in the last month

Please list all foods and/or medications you are allergic to

Please list any major surgeries you’ve had in the past, including the date and reason for the procedure

If you are you suffering any emotional or mental conditions, please explain

If you have you ever been admitted to a psychiatric hospital, please explain

If you have ever tried to commit suicide, please explain

Do you suffer from any of the following conditions? (check all that apply)

Do you suffer from any of these physical conditions? (check all that apply)

Do you or your family have any history of cardiac abnormalities, heart attack or stroke? (required)

Do you or your family have any history of long QT syndrome, sudden death or unexplained blackouts? (required)

Are you taking any steroids or hormones such as Human Growth Hormone? (required)

Have you ever had a CYP2D6 metabolism test? if so, what was the result?

If you've ever been a smoker, how much and how long

Please describe what you do in your career, work or study:

What do you hope to achieve from your ibogaine treatment? (your intention or reason for treatment...) (required)

Is there anything else you would like to say?

I hereby certify that the above information given are true and correct as to the best of my knowledge (tick the box)

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