Healing Retreat (14 days)

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1 Welcome

2 Choose the dates of your stay

3 Price

4 Participant Info

Phone *
Gender
How did you hear about us?
How many times have you sat with Ayahuasca? *	Never - it will be my first time 1 - 4 times 5 - 10 11 - 20 20 - 40 40+
Do you have any experience with a Master Plant Dieta? *	If yes, please mention which plants, when, and for how long.
Do you suffer from any of the following problems?	Cardiovascular disease including heart attacks Liver failure Kidney failure High/low blood pressure Dizziness or fainting Psychotic episodes Schizophrenia Epilepsy Bipolar disorder Diabetes (Type I or II) Asthma Autoimmune disease Recent surgery Past or recent dislocations or fractures Glaucoma Retinal detachment Recent or current infectious or communicable disease Digestive problems Lung problems Skin issues Difficulty with sleep Bladder or kidney trouble
Are you currently pregnant or breastfeeding?	Yes No
Do you have any history of mental illness or psychotic episodes? *	Yes No
If yes, please elaborate on your history of mental illness or psychotic episodes. *
Have you ever been hospitalized for psychiatric reasons or given a psychiatric diagnosis? *	Yes No
If yes, please explain in detail. *	Explain in detail your psychiatric hospitalization or diagnosis.
Are you currently taking any prescribed medications? *	Yes No
If yes, please list the pharmaceutical name of the medication(s), the length of use, and the dosage. *
Have you consulted with a healthcare professional about discontinuing use of the medication(s) you are currently taking?
Please list any previously prescribed medications.	Note the name of the medication(s), the length of use, and the dosage.
Have you required medical treatment or intervention in the past? *	Yes No
If yes, please state when, for what, and what the treatment protocol involved. *
Do you have any serious allergies to medications, food, or anything else?	Yes No
If yes, please list the allergies.
Have you used drugs recreationally in the past 6 months? *	Yes No
If yes, please list which drugs and how frequently. *
Please give us a brief description of your intention for coming to our center. *
Do you have any other comments?
Terms and Conditions *	I accept the terms and conditions.Please read the terms and conditions
Payments do not include the cost of plant medicines. *	I understand that payments made through Retreat Guru do not include the cost of: plant medicine, ayahuasca or similar products. There will be no additional charges for this retreat.Supplementary Products Exclusion: Participants acknowledge and agree that these Fees presented and payable pertain solely to Services and Offerings, and will not include the cost of any plant-medicines or similar products (collectively, "Supplementary Products") which may be provided, offered, or distributed by a Commercial User, or any other party, in connection with Services or Offerings. Retreat Guru shall bear no responsibility or liability in connection with any provision, offering, or distribution of Supplementary Products, and is not a party thereto. All capitalized terms used herein shall carry the same meaning as assigned to them in Retreat Guru's Terms of Service.

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1 Welcome

2 Choose the dates of your stay

3 Price

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4 Participant Info

5 Security Check

6 Payment