Ceremony Intake

Name

First Name

Last Name

Phone Number

Date of Birth

Sex

Emergency Contact

Do you have any medical conditions?

Are you currently taking any medications? If so, please list:

Do you currently suffer from any infectious or contagious disease?

Do you have any cardiovascular disease, including heart attacks?

Do you have any blood pressure condition (high or low blood pressure)?

Do you suffer from Asthma? If so, when is the last time you used an inhaler?

Do you use alcohol? If so how much per week?

Are you currently pregnant or breastfeeding?

Before sitting in prayer with a strong plant medicine, it’s imperative that we cover some basics to ensure a safe and grounded healing journey.

CEREMONY INTAKE