Confidential application

Thorough screening application for IV ibogaine infusion

This is a deeper intake — not a short inquiry. Fill out as much as you are comfortable with. The path is confidential intake → medical/psych readiness review → discovery call. We discuss true psychoactive intravenous ibogaine under physician supervision (consult → cardiac screen → monitored IV infusion → integration).

What this application covers

1. 1. Contact — how we reach you confidentially
2. 2. Interest — why IV ibogaine, concern, travel window
3. 3. General health — meds, conditions, EKG history (file optional later)
4. 4. Substance history — current/past patterns
5. 5. Eating & sleep — patterns and supports
6. 6. Personal & family — support, stressors, optional trauma detail
7. 7. Intentions & consent — goals and Mexico provisional acknowledgment

Trust bullets

• • Cardiac-first. Expect ECG/electrolyte discussion. Safety
• • Route honesty. Psychoactive IV, not oral flood marketed as “infusion.” Oral vs IV
• • No cure claims for addiction, depression, or PTSD.
• • Provisional Mexico. Not a U.S. FDA-approved clinic; screening required.

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