Medically Supervised Ibogaine Clinic in Mexico Begin Your Confidential Application Process Call Now: +1-800-827-3566 Step 1 of 7 - Introduction 0% NameThis field is for validation purposes and should be left unchanged.Introduction Thank you for applying for ibogaine treatment at Anzelmo. This form will take between 10-30 minutes to complete, depending on the answers that you provide. Please be as thorough and complete as possible. All of the information you provide here will be kept confidential and only shared with our medical team. This form and its delivery is encrypted for your online privacy. Do not use your browser's back button or you may lose the information you submitted. Use the "Previous" button provided on the following pages if you need to return to a section. When you're ready, click "Next" to advance to the next step. 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Yes No Secondary Emergency Contact Name First Last RelationshipPhoneEmail Treatment InformationHave you ever done ibogaine or iboga treatment before?* Yes No Describe your treatment history:*Please include where, when, for what purpose, and what you felt was the result.Are you seeking treatment for substance use issues?* Yes No Do you drink alcohol in any form or quantity?* Yes No How much do you drink and how often?*Do you smoke tobacco?* Yes No How much do you smoke, how often, and for how long?*Please provide a complete list of all non-prescribed medications and/or street drugs you have used in the past 30 days:Substance Use TreatmentDescribe your substance use:*Include information such as the substance, method of injestion, dosage, frequency, and how long you have been using.Psychospiritual TreatmentWhat are your goals with ibogaine treatment?*Treatment Date Requested DD slash MM slash YYYY Medical InformationDo you currently or have you ever had any of the following conditions:Please check all that apply. Not all of these conditions immediately rule out the possibility of ibogaine treatment, but it is important for us to have a clear understanding of your medical history. Epilepsy Cystic Fibrosis History of Ulcer Respiratory Problems Asthma Sleep Apnea Emphysema Shortness of Breath Gastrointestinal Problems Diarrhea Constipation Crohn's Disease Leaky gut syndrome Obesity Heart Disease Arrythmia Low Blood Pressure High Blood Pressure Heart Condition Heartburn History of Blood Clots Diabetes Numbness Muscle Spasm Migranes Fainting Urinary Problems Vericose Veins Nerve Problems Chronic Pain Back Problems Abdominal Pain Cancer Tuberculosis HIV/AIDS Hepititis A, B or C Thyroid Condition Excessive Menstruation Loss of Menstruation Head Injury Insomnia Are you pregnant?* Yes No Possibly List all over-the-counter medications and supplements you are taking:List all prescribed medications you are currently taking:Please include any anti-anxiety, anti-depressents, benzodiazepines, etc.List all prescribed medications you are currently NOT taking:Please include any anti-anxiety, anti-depressents, benzodiazepines, etc.Please list all foods and/or medications you are allergic to:Please list any major surgeries you’ve had in the past, including the approximate date and reason for the procedure:Do you get nauseus or vomit easily?* Yes No What provokes this nausea or vomiting?* Mental & Emotional HealthHave you been diagnosed with any mental or emotional conditions?* Yes No Please describe these diagnoses:Have you ever been admitted to a psychiatric hospital or treatment facility for these conditions? Yes No Please list approximate dates and detail the condition you were treated for:*Do you ever struggle with your mental or emotional health?* Yes No Please describe this experience:* Additional InformationPlease describe any plans you have in place for after your treatent:Would you like any additional information about aftercare coaching or residential after programs? Yes No Is there anything else you would like to tell us?How did you hear about us?Consent for ResearchOccasionally, our staff or medical team may collect and present medical information about patients in our care for the purpose of advancing the scientific discourse, publishing or presenting interesting case studies or anomalous treatment events, or preparing statistics, etc. Do you consent to us using any information about your treatment in this way? This does not include your name, or any other personally identifying information.Do you consent?* Yes No I would like more information before consenting ConfirmationBy typing your name in the box below you certify that all of the information that you have provided here is complete and accurate to the best of your knowledge.Confirmation*Type your name in the field below Δ
