Apply For Treatment Online ApplicationStep 1 of 714%Name* First Last GenderMaleFemaleAgeWeightHeightPrimary Phone:*Email* For Emergency Contact: Full name, address, phone number and email address for your two closest family members or friends:Are you seeking treatment for Substance Addiction?YesNoTreatment Date Requested List specific addictions and usage amount:Excluding the drugs listed above, please provide a complete list of substances used in the last 30 days:Please provide a brief history of your addiction or the condition you are seeking treatment for:What do you hope to achieve from our Ibogaine treatment?: List all over-the-counter medications and supplements you are taking:Have you been diagnosed with any emotional or mental conditions?:List all prescribed medications you are taking (including anti-anxiety, anti-depressents, benzodiazepines, etc.):List all prescribed medications you are currently not taking (including anti-anxiety, anti-depressents, benzodiazepines, etc.):Please provide a complete list of all non-prescribed medications and/or street drugs you have used in the past 30 days: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: What is your last blood pressure reading?What is your normal resting pulse rate?Do you drink alcohol?YesNoIf yes, how much do you drink, and how often?Have you ever admitted to a psychiatric hospital?YesNoIf yes, please list approximate dates and detail the condition you were treated for:Do you have hypertension or hypotension?:YesNo Do you have a history of myocardial infarction or heart disease? If yes, please explain:Do you have a history of seizure? If yes, please explain:Do you have history of vascular disease including aneurysms? If so, how is it being treated?Do you have a history of embolism, problems with blood clotting, or recent trauma to the body including the pelvis or legs? If yes, please explain:Do you have diabetes? If yes, are you insulin dependent?Do you have hypoglycemia? If yes please explain:Do you have fainting spells or get dizzy when getting up suddenly? If yes please explain: Have you ever had surgery to your gastrointestinal tract or have a history of disease including ulcerative colitis, Crohn's Disease, bleeding or peptic ulcer? If yes please explain:Do you have any type of hepatitis including abnormal liver function tests, hepatitis C, primary biliary cirrhosis, elevated serum ammonia levels, etc.? If yes please explain:Do you get nauseous easily? If so, what has triggered this reaction?Have you ever coughed up or vomited blood? If yes please explain:Do you have insomnia? If yes please explain:Do you consider yourself to be depressed? If yes please explain:Have you ever tried to commit suicide? If yes please explain: Do you have any type of brain damage including traumatic or closed head injury with or without unconsciousness, or seizure? If yes please explain:Are you a cigarette smoker? If so, how much and how long?Are you asthmatic? If so, do you use an inhaler?Do you suffer from or have you suffered from any of the following physical conditions? (Check all that apply.): Diabetes Bleeding History of Ulcers Thyroid Problems Low Blood Pressure Loss of Menstruation Cancer Joint Pain Diarrhea Nausea Tuberculosis Renal Disease Heartburn Stroke Abdominal Pain Jaundice Heart Problems Respiratory Problems Painful Menstruation Swelling Numbness Back Problems Shaking High Blood Pressure Muscle Spasm Constipation Hepatitis A, B, or C Stomach Problems Urinary Problems Heart Disease Asthma Excessive Menstruation Fainting Varicose Veins HIV Positive / AIDS Dizzy Spells Shortness of Breath Nerve Damage Obesity NONE OF THE ABOVEIs there anything else you would like to tell us?How did you hear about us? This iframe contains the logic required to handle AJAX powered Gravity Forms.