Contact Form
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Step
1
of 2
Confirm your Spain Retreats 2025
*
06 - 10 March
13-17 March
20-24 March
27-31 March
03-07 July
10-14 July
17-21 July
24-28 July
6-10 November
13-17 November
20-24 November
27 November-01 December
Name
First
Last
Date of Birth
Email Address
*
Phone Number
Passport Number
Gender
Male
Female
Do you have any special dietary requirements/food allergies?
Yes
No
If yes please specify.
Emergency Contact Person's Name & Relationship
Emergency Contact Person's Phone Number
Next
Medical Questions
All information that you give us below is treated in the strictest confidence, please do not withold any information as your safety is paramount.
If the question does not apply you to please input N/A into the box
Have you taken Ayahuasca before?
Yes
No
If yes, how many times?
Have you experienced adverse or particularly difficult experiences with ayahuasca that you have found hard to integrate?
Yes
No
If yes, please specify below
Do you have a past history of, or currently suffer from any serious health conditions?
Yes
No
If yes, please specify below
Are you currently pregnant or breastfeeding?
Yes
No
If yes, please specify below
Have you ever been pregnant?
Yes
No
If yes, please specify below
Have you ever terminated a pregnancy? Voluntarily or Involuntarily?
Yes
No
If yes, please specify below
Have you ever been hospitalized for medical reasons or had any surgeries?
Yes
No
If yes, please specify below
Do you suffer from autism or Asperger's?
Yes
No
If yes, please specify below
Have you taken the Covid vaccine?
Yes
No
If yes, please specify number of vaccines and brand below
Have you ever broken any bones?
Yes
No
If yes, please specify below
Do you have any gastric issues?
Yes
No
If yes, please specify below
Do you suffer from any heart or blood pressure issues?
Yes
No
If yes, please specify below
Do you suffer from any lung or respiratory problems?
Yes
No
If yes, please specify below
Do you suffer from diabetes?
Yes
No
If yes, please specify below
Do you suffer from any liver or kidney problems?
Yes
No
If yes, please specify below
Do you suffer from epilepsy?
Yes
No
If yes, please specify below
Do you take any medications prescribed by a doctor? Or any over the counter medications from a pharmacy?
Yes
No
If yes, please specify and list the medications dosage and frequency taken. (Please note that it is imperative that you list all medications, as the plant medicine can interact with certain medications in a way that can be dangerous.)
Do you have any history of depression, anxiety, addictions ,PTSD, psychosis, bipolar illness, personality disorder or schizophrenia?
Yes
No
If yes, please specify below
Have you ever been a victim of physical or sexual abuse? We understand that this is a highly sensitive matter. It is important for us to know the extent and severity of these experiences so we can support you in the best way possible during your work with the medicine.
Yes
No
If yes, please specify below
Have you taken any recreational substances that you have taken over the past 12 months? (Including alcohol and marijuana)
Yes
No
If yes, please specify below
What is your purpose for drinking Ayahuasca?
Have you suffered from any past emotional trauma that we should know about?
Yes
No
If yes, please specify below
Additional Information you would like the Shaman to know:
I hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly and have not withheld any information. My general health, as far as I am aware, is good.
I am assured that the information provided will remain strictly confidential and will serve only as a guide in determining the appropriateness of my participation in the ceremony and in meeting my needs before, during and after the ceremony.
Consent and Liability: I am participating voluntarily and of my own free will, in these ceremonies, in which Ayahuasca (a known psychoactive substance) is used. I understand that my participation in these ceremonies may be physically, mentally, emotionally or spiritually demanding. I release the organizers and all Yagewaska team from any responsibility for mental or physical harm to my person following the use of the substance described above, or resulting from my participation in these ceremonies.
Submit and continue