Medical Information FormMedical Information Form Participant First Name * Participant Last Name * Participant Email * Date of Birth * Emergency Contact * Emergency Contact Phone * Relationship to Participant * Medication Allergies Food Allergies Other Allergies (insects, hay fever, asthma, etc.) Current Medications & Dosage Current Supplements & Dosage Do you agree to abstain from taking all medications, supplements, and drugs (including cannabis) 24 hours before any sacred medicine ceremony? Yes Have you ever been diagnosed with bi-polar disorder, schizophrenia, epilepsy, or grand mal seizures? * Select One...NoYes Is there any other important medical information you need to share? Primary Care Physician Name * Primary Care Physician Phone Number * Insurance Company Policy and/or Group # Insurance Company Address Insurance Company Phone Number Submit If you are human, leave this field blank. Δ|PsychedelicIQ UpdatesDon't miss out on new resources, training, and upcoming events.First NameJohnLast NameSmithYour emailjohnsmith@example.comSubscribe
