Complete the form below to begin the conversation
In order to ensure your safety during this event it is important that we have full knowledge of the questions below. Please be as honest as possible as this helps us determine if certain medicinal substances are right for you. Please be assured that the information you provide will be held confidentially and sent via this secure form. If we determine that the medicinal substances in this event would not be a good fit for you we will send you a private message and issue a full refund for any payment or deposits you provide.
There is a field to input explanations at the end of the section. Thank You
We've provided two lists of medications, with the second list being more comprehensive yet lacking details about the types of medications. This format can be helpful for those familiar with medication names but not their classifications, which are important for identifying contraindications. Medications within the same class often have similar names. If you recognize a medication on the first list that is similar to one you are taking but isn’t listed on either, please notify us. We continuously update these lists to keep pace with new medication releases.
MAOI
SSRIs:
SNRIs:
NRIs:
NDRIs:
TCAs:
TeCAs and NaSSAs:
SMSs:
Benzodiazepines:
Non-benzodiazepine sleep medications:
Barbiturates:
Heart and Blood Pressure Medication:
Herbal Supplements/Medications:
• Other MAO-Is • SSRIs (any selective serotonin reuptake inhibitors) • Asthma inhalers • Antihypertensives (high blood pressure medicine) • Appetite suppressants (diet pills) • Medications for asthma, bronchitis, or other breathing problems • Antihistamines, medicines for colds, sinus problems, hay fever, or allergies (any cold, cough, or flu preparations, and any drug with DM, DX or -tuss in its name.) • CNS (central nervous system depressants • Antipsychotics • Barbiturates • Tranquilizers • Sympathomimetic amines (including pseudoephedrine and ephedrine) • Alcohol • Amphetamines • Opiates • Mescaline (any phenethylamine) • Barbiturates
Specific Contraindicated Drugs (3, 5): • Actifed • Adderall • Alaproclate • Aalbuterol (Proventil, Ventolin) • Amantadine hydrochloride(Symmetrel) • Amineptine • Amitriptaline • Amoxapine(Asendin) • Asarone/Calamus • Atomoxedine • Befloxetone •Benadryl • Benylin • Benzedrine • Benzphetamine (Didrex) •Bicifadine • Brasofensine • Brofaromine • Bromarest-DM or -DX• Bupropion (Wellbutrin) • Buspirone (BuSpar) • Butriptyline •Carbamazepine (Tegretol, Epitol) • Chlorpheniramine • ChlorTrimeton • Cimoxetone • Citalopram • Clomipramine(Anafranil) • Cocaine • Codeine • Compoz • Cyclobenzaprine(Flexeril) • Cyclizine (Marezine) • Dapoxotine •Desipramine(Pertofrane, Norpramin) • Desvenlafaxine •Dextroamphetamine (Dexedrine) •Dextromethorphan (DXM) •Dibenzepin • Dienolide kavapyrone desmethoxyyangonin •Diethylpropion •Dimetane-DX • Disopyramide (Norpace) •Disulfiram (Antabuse) • Dopamine (Intropin) 5 of 9 •Dosulepin •Doxepin (Sinequan) • Dristan Cold & Flu • Duloxetine • Emsam •Ephedrine • Epinephrine (Adrenalin) •Escitalopram •Femoxitine • Fenfluramine (Pondimin) • FlavoxateHydrochloride (Urispas) • Fluoxetine(Prozac) • Fluvoxamine •Furazolidone (Furoxone) • Guanethedine • Guanadrel (Hylorel) •Guanethidine (Ismelin) • Hydralazine (Apresoline) • 5Hydroxytryptophan • Imipramine (Tofranil) • Iprindole •Iproniazid (Marsilid, Iprozid, Ipronid, Rivivol, Propilniazida) •Iproclozide • Isocarboxazid (Marplan) • Isoniazid (Laniazid,Nydrazid) • Isoniazid rifampin (Rifamate, Rimactane) •Isoproterenol (Isuprel) • L dopa (Sinemet) • Levodopa (Dopar,Larodopa • Linezolid (Zyvox, Zyvoxid) • Lithium (Eskalith) •Lofepramine • Loratadine (Claritin) • Macromerine • Maprotiline(Ludiomil) • MDA • MDEA • MDMA (Ecstasy) • Medifoxamine •Melitracen • Meperidine (Demerol) • Metaproterenol (Alupent,Metaprel) • Metaraminol (Aramine) • Methamphetamine(Desoxyn) • Methyldopa (Aidomet) • Methylphenidate (Ritalin)6 of 9 • Mianserin • Milnacipran • Minaprine • Mirtazapine(Remeron) • Moclobemide • Montelukast (Singulair) •Nefazodone • Nialamide • Nisoxetine • Nomifensine • Norepinephrine (Levophed) •Nortriptyline (Aventyl) •Oxybutynin chloride (Ditropan) • Oxymetazoline (Afrin) •Orphenadrine (Norflex) • Pargyline (Eutonyl) • Parnate •Paroxetine (Paxil) • Pemoline (Cylert) • Percocet • Pethedine(Demerol) • Phendimetrazine (Plegiline) • Phenelanine •Phenergen • Phenmetrazine • Phentermine • Phenylephrine(Dimetane, Dristan decongestant, Neo Synephrine) •Phenylpropanolamine (in many cold medicines) • Phenelzine(Nardil) • PMA • Procarbazine (Matulane) • Procainamide(Pronestyl) • Protriptyline (Vivactil) • Pseudoephedrine •Oxymetazoline (Afrin) • Quinidine (Quinidex) • Rasagiline(Azilect) • Reboxetine • Reserpine (Serpasil) • Risperidone •Robitussin • Salbutemol • Salmeterol • Selegiline (Eldepryl) •Sertraline (Zoloft) • Sibutramine 7 of 9 • Sumatriptan (Imitrex) •Terfenadine (Seldane D) • Tegretol • Temaril • Tesofensine •Theophylline (Theo Dur) • Tianeptine • Toloxatone • Tramidol •Tranylcypromine (Parnate) • Trazodone • Tricyclic antidepres-sants (Amitriptyline, Elavil) • Trimipramine (Surmontil) •Triptans • Tryptophan • Tyrosine • Vanoxerine • Venlafaxine(Effexor) • Viloxezine • Vicks Formula 44-D • Yohimbine •Zimelidine • Ziprasidone (Geodon)
Please be as forthcoming as possible when answering the questions above. If any potential medical contraindications are present, we will inquire further to ensure your safety. By registering for a program, you are declaring that you are in physical and mental condition appropriate to the activities described, that you agree to participate at your own risk, and that we cannot accept liability for any accident or injury. We will provide the most secure environment to work with 5-MEO-DMT as much as possible and ensure your welfare to the best of our abilities, at all times. In return, we ask that you behave responsibly and do not endanger yourself or others.
Working with 5-MEO-DMT can carry health risks; please disclose any known medical conditions. Please contact us before making a reservation to discuss your particular case (e.g. tuberculosis). can be dangerous to those with a history of psychological conditions. Please inform us of any history of mental health problems in the past. It is important to suspend any kind of psycho-pharmaceutical and depression treatments 14 to 35 days before taking 5-MEO-DMT. We will provide more specific advice on how to proceed under the supervision of your doctor once we receive details of a particular medication in question. It is preferable to not take any other substances that may cause interference with the medicine’s energy and provoke unwanted reactions. Certain drugs and medications have been found to not be compatible with some medicines. It is essential to stop taking the substances listed in this document and give your system sufficient time to remove them from the body before you begin a program. We will provide advice on how to proceed during your booking process. Please consult your doctor if you are in any doubt. You should not stop taking prescribed medications without consulting your doctor.
Code of Conduct & Sexual Integrity Agreement
It is important to understand that you are in a creative ceremony from the moment you arrive until we close the circle together. We require guests to be intentional about their creations during our time together, and so we request:
Sexual Integrity Agreement
As we embark on this journey together, we open many gateways to creative energy and healing. We expand our creative capacity and shed layers of ourselves, revealing deeper parts that may have been previously unreachable. To maintain a safe environment, we ask for all participants are asked to refrain from sexual activity during the event.
I hereby grant permission for the rights to my image, likeness, and sound of my voice as recorded on audio or videotape, without payment or any other compensation. I understand that my image may be edited, copied, exhibited, published, or distributed, and I waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising from or related to the use of my image or recording.
By signing this release, I understand that photographic or video recordings of me may be electronically displayed via the Internet or in a public educational setting.
I will be consulted about the use of the photographs or video recordings for any purpose other than those listed above.
There is no time limit on the validity of this release, nor are there any geographic limitations on where these materials may be distributed.
This release applies to photographic, audio, or video recordings collected as part of the sessions listed in this document only.
I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING OR ATTENDING THIS ACTIVITY OR EVENT, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by the event, or because of their possible liability without fault. I certify that I am physically fit and have completed the medical questionnaire and/or have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this activity or event. I acknowledge that this Accident Waiver and Release of Liability Form will be used by the event holders, sponsors, and organizers of the retreat/event, and that it will govern my actions and responsibilities at said activity or event. In consideration of my application and permitting me to participate in this event, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:
WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this event.*
INDEMNIFY, HOLD HARMLESS, AND WILL NOT TO SUE the entity and/or persons organizing this event and waive them from any and all liabilities or claims made as a result of participation in this activity or event, whether caused by the negligence of release or otherwise. I acknowledge that this activity or event may test a person’s physical and mental limits and may carry with it the potential for death, serious injury, and property loss. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, event officials, and event monitors, and/or producers of the event, and lack of hydration. These risks are not only inherent to participants, but are also present for volunteers. I am aware that physical activity will increase my risk of hypoglycaemia due to my condition (type 1 diabetes mellitus) and I will ensure that I will take every preventative precaution necessary. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity or event. I understand that at this event or related activities, I may be photographed. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers, and assigns. The accident waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL*