Patient Application Form

Personal Information
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Emergency Contact Information
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Privacy Policy
1. Information We Collect

We may collect the following types of information:
- Personal Information: Name, date of birth, contact details, address, passport/ID details.
- Medical Information: Medical history, medications, test results (EKG, bloodwork, liver function panel), mental health history, and treatment notes.
- Payment Information: Billing name, contact, and transaction details (handled by secure payment processors; we do not store full credit card data).
- Travel & Stay Information: Arrival and departure details, emergency contact information, and accommodations preferences.
2. Purpose of Collection

Your information is collected solely to:
- Evaluate your eligibility and safety for Ibogaine therapy.
- Provide appropriate medical supervision and support.
- Maintain accurate records of treatment and outcomes.
- Communicate logistics, follow-up care, and integration guidance.
- Comply with legal and medical obligations.
3. Confidentiality of Medical Records

All medical and personal information is strictly confidential.
- Records are stored securely, accessible only to authorized Iboga Wellness Centers staff.
- Information will never be shared with third parties without your consent, unless required by law or in cases of medical emergency.
4. Data Security
- Electronic records are stored on encrypted, password-protected systems.
- Physical documents are secured in locked cabinets with restricted access.
- Staff are trained in confidentiality and privacy best practices.
5. Your Rights

You have the right to:
- Access your personal and medical records upon request.
- Request correction of inaccurate information.
- Withdraw consent for future use of your information (with the understanding that certain medical/legal requirements may apply).
- Request deletion of your non-medical data after your treatment has concluded.
6. Sharing of Information

We do not sell, trade, or rent your information. Information may only be shared:
- With medical staff directly involved in your treatment.
- With emergency medical providers, if necessary to protect your health.
- If required by Mexican law, international law, or public health authorities.
7. International Guests

As many of our guests travel from the United States, Europe, and abroad:
- We adhere to standards similar to HIPAA (U.S.) and GDPR (EU) where applicable.
- All cross-border data transfers are handled with strict confidentiality.
8. Retention of Records
- Medical records will be kept for a minimum of 5 years, as required by medical best practices in Mexico.
- Non-medical information may be securely deleted upon request after your treatment is complete.
9. Contact Information

For questions about this Privacy Policy or to exercise your rights, please contact:
Iboga Wellness Centers
- Email: james@ibogawellnesscenters.com
- Phone: +1 (800) 604-7294
- Website: www.ibogawellnesscenters.com
10. Policy Updates

We may update this Privacy Policy periodically to reflect best practices or changes in legal requirements. Any updates will be communicated directly to guests prior to their treatment.
Privacy Policy Acceptance*

I confirm that I have read and agree to the Iboga Wellness Centers Privacy Policy, and consent to the collection and use of my information as described.

Ibogaine Therapy Consent
1. Consent for Treatment

I, hereby referred to as “the Patient”, voluntarily consent to participate in the Ibogaine therapy monitored by Iboga Wellness Centers. I understand that this therapy involves Ibogaine, a psychoactive substance derived from the Tabernathe iboga plant, used in the treatment of substance dependency, PTSD, depression, anxiety, and for personal growth.

2. Risks and Benefits

I acknowledge that I have been informed about the potential benefits, risks, and side effects associated with Ibogaine therapy, including but not limited to: changes in heart rate, blood pressure, nausea, hallucinations, emotional and psychological revelations, and in rare cases, severe health complications.

3. Pre-Screening and Health Assessment

I confirm that I have undergone a comprehensive pre-screening and health assessment, including an EKG, blood work, and liver panel, conducted by Iboga Wellness Centers’ onsite medical doctor. I have disclosed all relevant medical history, current medications, and substance use to ensure my suitability for Ibogaine therapy.

4. Voluntary Participation

I acknowledge that my participation in this therapy is entirely voluntary and that I have the right to withdraw my consent and discontinue participation at any time.

5. Confidentiality

I understand that my privacy will be respected, and all personal and medical information will be handled in accordance with Iboga Wellness Centers’ privacy policy and applicable laws regarding patient confidentiality.

6. Liability Release

I, the undersigned, formally absolve Iboga Wellness Centers, along with its employees and associated entities, from any claims, liabilities, or damages that may result from my engagement in the Ibogaine therapy program. I acknowledge that Iboga Wellness Centers assumes a supplementary role, offering professional and medical support in the event of an emergency.

7. Payment Collection by Iboga Wellness Centers LLC

Iboga Wellness Centers LLC oversees payment collection. We handle fees for all aspects of your stay, including medical supervision, program costs, food, accommodations, and any non-medical expenses related to your visit.

8. Payment Collection by Iboga Wellness Centers LLC

I have read this consent form (or have had it read to me) in its entirety. I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction. I hereby acknowledge my understanding that, during the Ibogaine therapy process, Iboga Wellness Centers’ role is exclusively to monitor participants to ensure their safety. I agree to adhere to all terms and conditions specified in this consent form.
Consent for Treatment*

I, hereby referred to as “the Patient”, voluntarily consent to participate in the Ibogaine therapy monitored by Iboga Wellness Centers. I understand that this therapy involves Ibogaine, a psychoactive substance derived from the Tabernathe iboga plant, used in the treatment of substance dependency, PTSD, depression, anxiety, and for personal growth.
Risks and Benefits*

I acknowledge that I have been informed about the potential benefits, risks, and side effects associated with Ibogaine therapy, including but not limited to: changes in heart rate, blood pressure, nausea, hallucinations, emotional and psychological revelations, and in rare cases, severe health complications.
Pre-Screening and Health Assessment*

I confirm that I have undergone a comprehensive pre-screening and health assessment, including an EKG, blood work, and liver panel, conducted by Iboga Wellness Centers’ onsite medical doctor. I have disclosed all relevant medical history, current medications, and substance use to ensure my suitability for Ibogaine therapy.
Voluntary Participation*

I acknowledge that my participation in this therapy is entirely voluntary and that I have the right to withdraw my consent and discontinue participation at any time.
Confidentiality*

I understand that my privacy will be respected, and all personal and medical information will be handled in accordance with Iboga Wellness Centers’ privacy policy and applicable laws regarding patient confidentiality.
Liability Release*

I, the undersigned, formally absolve Iboga Wellness Centers, along with its employees and associated entities, from any claims, liabilities, or damages that may result from my engagement in the Ibogaine therapy program. I acknowledge that Iboga Wellness Centers assumes a supplementary role, offering professional and medical support in the event of an emergency.
Payment Collection by Iboga Wellness Centers LLC*

Iboga Wellness Centers LLC oversees payment collection. We handle fees for all aspects of your stay, including medical supervision, program costs, food, accommodations, and any non-medical expenses related to your visit.
Payment Collection by Iboga Wellness Centers LLC*

I have read this consent form (or have had it read to me) in its entirety. I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction. I hereby acknowledge my understanding that, during the Ibogaine therapy process, Iboga Wellness Centers’ role is exclusively to monitor participants to ensure their safety. I agree to adhere to all terms and conditions specified in this consent form.

Service Agreement
Between: Iboga Wellness Centers, LLC(“Provider”) and (“Patient”)

1. Purpose of Agreement

This Agreement sets forth the terms and conditions under which Iboga Wellness Centers, LLC will provide wellness and therapeutic services to the Patient. The services are focused on supporting patients' health and well-being while addressing symptoms associated with Parkinson’s disease.

2a. Pre-Treatment Services Provided

Provider agrees to deliver the following services prior to the Patient’s arrival for Onsite Treatment Services:
- Identification of medical screening processes and tests which Provider requires to be administered to the Patient in order for the Provider to Qualify/Approve the Patient for treatment.
- Provider to issue a written, electronically signed Treatment Qualification/Approval letter.
2b. Onsite Treatment Services Provided

Provider agrees to deliver the following services for a 14-day period from 10/27-11/10 2025 at clinic in Cozumel Mexico:
1. Wellness support and therapeutic care.
2. Administration of ibogaine-based microdosing protocols in accordance with Dr. Omar Calderon’s clinical guidelines.
3. Medical monitoring during treatment, including regular EKG and heart monitoring, vital sign checks, any medicines needed and observation of overall physical condition to ensure safety.
4. Education, preparation, and integration sessions designed to maximize treatment benefit.
5. Daily Physical Therapy or Aqua Sessions.
6. Daily Yoga sessions.
7. Weekly Massage sessions.
8. Weekly boat excursion to a sandbar for lunch or dinner if the patient is able.
9. Daily meals (breakfast, lunch, dinner and meals) provided by our personal Chef and staff.
10. Transportation to and from the Airport in private transportation and private transportation around the island.
11. Concierge services available to ensure a 5 star experience for each patient.
12. Phycologist available to each patient if needed.
2c. Post-Treatment Services Provided
- The provider agrees to provide the following services remotely.
- Once a week Zoom calls with patients for 3 months following Treatment to assess Post-Treatment condition and collect data needed to assess effectiveness of Treatment over time.
- Once a month Zoom calls a Patient for months 4-12 following Treatment to assess Post-Treatment condition and collect data needed to assess effectiveness of Treatment over time.
- Assistance with obtaining ibogaine for Patient assuming Provider deems that to be appropriate.
3. Acknowledgment of Treatment Purpose

Patient acknowledges that:
- Treatment is being sought for Parkinson’s disease and related symptoms.
- The services provided are considered alternative and experimental therapy, and outcomes may vary.
- No guarantee of improvement or cure is made or implied.
4. Fees and Payment

Payment Schedule:

50% of the total program fee (USD) is due upon issuance of the electronically signed Treatment Qualification/Approval letter. The remaining 50% (USD) is due no later than three (3) days prior to the patient’s scheduled arrival at the clinic. If paying by card, a 3% processing fee applies to the amount paid by card.

5a. Cancellation & Refund Policy
- Cancellations made at least 30 days before your scheduled treatment date are eligible for a full refund of the program fee (minus any transfer or processing costs).
- Cancellations made less than 21 days before your scheduled treatment may result in forfeiture of ½ your deposit.
- Cancellations made less than 14 days before your scheduled treatment may result in forfeiture of ¾ your deposit.
- Cancellations made less than 7 days before your scheduled treatment may result in forfeiture of your full deposit.
- Postponements can be arranged at our discretion and based on availability.
5b. Disclaimer Of Liability
- I release Iboga Wellness Centers, its medical team, therapists, administrative, and operational staff from all medical, legal, and administrative responsibility for any consequences arising from my decision not to undergo the recommended treatment.
- I understand that my decision to refuse services today will not result in a refund, as long as reschedule to commence services with 90 days.
- I declare that my decision has been made without coercion, external pressure, or undue influence and that I have fully understood the explanations provided.
- I agree not to take legal action against Iboga Wellness Centers, its medical staff, therapists, or administrative team in relation to my decision not to accept the proposed treatment.
6. Risks and Limitations

Patient understands and accepts that:
- Ibogaine carries potential physical and psychological risks, including but not limited to: changes in blood pressure, heart rhythm irregularities, nausea, dizziness, emotional distress, and other medical complications.
- No guarantee of improvement or cure is provided.
- Patients must disclose all relevant medical history, medications, and conditions to the Provider prior to treatment.
- Emergency medical care may be required in rare cases, and the patient consents to such care if deemed necessary by the provider.
7. Patient Responsibilities

Patient agrees to:
1. Provide full and accurate medical history.
2. Follow all instructions before, during, and after treatment.
3. Refrain from alcohol, recreational drugs, and any medications contraindicated with ibogaine, as directed by the Provider.
4. Immediately report any concerning symptoms to the Provider.
8. Confidentiality

All medical and personal information will be kept confidential in accordance with applicable privacy laws in Mexico.

9. Consent to Treatment

By signing this Agreement, Patient acknowledges and consents to the following:
- I voluntarily choose to receive treatment at Iboga Wellness Center in Cozumel Mexico.
- I understand the treatment involves ibogaine microdosing following Dr. Omar Calderón’s protocol.
- I have been informed of potential risks, benefits, and alternatives.
- I understand this treatment is alternative and experimental and not guaranteed to improve my condition.
- I release Iboga Wellness Centers, LLC, its staff, contractors, and affiliates from liability for outcomes reasonably associated with treatment, except in cases of gross negligence or willful misconduct.
10. Governing Law

This Agreement shall be governed by and construed in accordance with the laws of Mexico.

11. Entire Agreement

This Agreement contains the entire understanding between Provider and Patient regarding the subject matter and supersedes all prior discussions or agreements.
Service Agreement Acceptance*

I confirm that I have read, understood, and agree to the terms outlined in the Service Agreement between Iboga Wellness Centers, LLC (“Provider”) and myself (“Patient”), and consent to receive the described wellness and therapeutic services under these conditions.

Iboga Wellness Centers Release Consent
Acknowledgment and Consent

I, the undersigned, acknowledge and agree to the following:

Voluntary Participation:
- I understand that my participation in Iboga Wellness Centers is entirely voluntary and that I can withdraw at any time.
Medical Conditions:
- I have disclosed all known medical conditions, including physical and mental health issues, to the Iboga Wellness Centers staff.
- I understand that ibogaine and psilocybin treatments can have significant physiological and psychological effects and may interact with other medications.
Risks:
- I am aware of the potential risks associated with ibogaine and psilocybin therapy, including but not limited to cardiac events, psychological distress, and drug interactions.
- I acknowledge that these treatments should be conducted under medical supervision and in a controlled environment.
Medical Supervision:
- I agree to follow all guidelines and instructions provided by the medical and support staff at Iboga Wellness Centers.
- I consent to any necessary medical intervention should an emergency arise during my participation in the retreat.
Confidentiality:
- I understand that my personal information and any data collected during the retreat will be kept confidential and used only for the purposes of providing care and treatment.
Waiver of Liability:
- I release Iboga Wellness Centers, its owners, staff, and affiliates from any liability, claims, or demands that may arise from my participation in the retreat, including but not limited to personal injury, psychological trauma, or death.
Compliance:
- I agree to adhere to the rules and guidelines set forth by Iboga Wellness Centers to ensure a safe and conducive environment for all participants.
Consent to Treatment Acceptance*

I have read and understood the above information. I acknowledge that I have had the opportunity to ask questions and that my questions have been answered to my satisfaction. I voluntarily agree to participate in Iboga Wellness Centers and consent to the administration of ibogaine and/or psilocybin therapies as outlined.

Patient Acknowledgment & Signature
Final Acknowledgment & Acceptance*

I confirm that all the information I have provided in this form is true and complete to the best of my knowledge, and that I have read, understood, and accepted all sections, including the Privacy Policy, Ibogaine Therapy Consent, Service Agreement, and Release Consent of Iboga Wellness Centers.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Personal Information

Emergency Contact Information

Medical Health History

Health Information

Medical History

Privacy Policy

1. Information We Collect

2. Purpose of Collection

3. Confidentiality of Medical Records

4. Data Security

5. Your Rights

6. Sharing of Information

7. International Guests

8. Retention of Records

9. Contact Information

10. Policy Updates

Ibogaine Therapy Consent

1. Consent for Treatment

2. Risks and Benefits

3. Pre-Screening and Health Assessment

4. Voluntary Participation

5. Confidentiality

6. Liability Release

7. Payment Collection by Iboga Wellness Centers LLC

8. Payment Collection by Iboga Wellness Centers LLC

Service Agreement

1. Purpose of Agreement

2a. Pre-Treatment Services Provided

2b. Onsite Treatment Services Provided

2c. Post-Treatment Services Provided

3. Acknowledgment of Treatment Purpose

4. Fees and Payment

5a. Cancellation & Refund Policy

5b. Disclaimer Of Liability

6. Risks and Limitations

7. Patient Responsibilities

8. Confidentiality

9. Consent to Treatment

10. Governing Law

11. Entire Agreement

Iboga Wellness Centers Release Consent

Acknowledgment and Consent

Patient Acknowledgment & Signature