Medical History
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Check the conditions that apply to you or to any members of your immediate relatives:
*
Asthma
Cardiac disease
Diabetes
Psychiatric disorder
Epilepsy
Stroke
On medication for low blood pressure
Had a brain haemorrhage
Had chemo in the last 4-6 weeks
Addison’s disease
Aneurisms or blood clots
EDS
Current or severe epilepsy
Recovering from surgery
Other
Check the symptoms that you're currently experiencing:
*
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Neurological
Psychiatric
Gastrointestinal
Weight gain
Weight loss
Health conditions?
Do you have any medication allergies?
*
Yes
No
Not Sure
Are you currently taking any medication?
*
Yes
No
Please specify medications
Have you had a covid 19 vaccine
*
Please Select
Yes
No
Have you taken plant medicine In The past?
*
Yes
No
Date & which plant medicine?
Do you use or do you have history of using illegal drugs?
*
Yes
No
Please specify drugs & usage
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
By signing this you have been honest with your replies. I understand & agree to partake in the healing treatment. Payments, Cancellations and RefundsAll ceremonies, treatments, services and products must be paid for in full in advance (At time of booking or purchase). By Bank Transfer or Cash if booking in person.CancellationsIf you need to cancel please give as much warning as possible as this will affect the amount you are refunded.Refunds If cancelling with 72 + hours notice a refund of 50% of the cost will be issued. Cancellations with less than 72 hours notice - no refund given. If cancellation of event is made by me, a full refund or credit will be issued.
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