Pretty Profundo

Peru Pre-screen form

Full Name (First and Last)

Phone Number

Email Address

Occupation

Emergency Contact Name

Home Address

Nationality

Date of Birth

Name of Event Attending

Emergency Contact Phone Number

Thank you for answering the following questions in complete honesty. All organizers related to this event decline all responsibility for any problems arising from the failure or lack of truthfulness in the answers to the following questions.

Its is in your interest and responsibility to inform us of any medical condition / Intake of medicine and dietary changes 2 WEEKS Prior to your retreat. We want to cater to your needs. Please select the approriate choice that you have read and understand the Pre / Post diet requirements and that you will inform us / organizer regarding any Medical condition / intake of medicine / dietary changes 2 weeks prior to your retreat.

Please select the appropriate choice that you have read and understand the pre / post diet requirements and that you will inform Pretty Profundo regarding any medical condition / intake of medicine / dietary changes 2 weeks prior to your retreat or earlier.

I AGREE

I DO NOT AGREE

Following questions are required.

ALL INFORMATION WILL BE KEPT CONFIDENTIAL

Have you Experienced any of the following Medicines

Ayahuasca

Kambo

Master Plant Dieta

Other

None

Please state when and how many times

In Ceremonial context?

Yes

Was it an enriching experience for you?

Yes

Have you experienced altered states of consciousness?

Yes

If so, what was it with?

Please tell us why you would like to experience Ayahuasca

Please let us know your medical information

Other

Do you have any of the following:

Liver Dysfunction or Disease

Heart Disease or Cardiovascular dysfunction

Digestive tract disease or dysfunction

Respiratory dysfunction or disease

Kidney disease or dysfunction

Mental health or special psychological condition

Blood Sugar dysfunction or Diabetes

Depression or Anxiety

Unlisted Disease or Dysfunction

Please specify illness, medication and date of diagnoses

How is your blood pressure?

Low

High

Normal

Not Sure

Please specify medical cause of blood pressure condition, medication and date of diagnoses

Are you taking any medication right now or taken any in the last month?

Yes

Please list medications and dates and frequency taken

Please list any not on the list that you have taken

NOTE: Be aware and mindful of if you are taking any kind of recreational drugs, sleeping pills, or antidepressants medicine you need to stop taking them at least 4 weeks prior the retreat, as well get a clearance and consult from your doctor for your own wellbeing.

If you consider yourself to have a dependency to any substance please state which ones below

If there is any history of mental illness in your family please describe below:

Any additional information you consider necessary please state below:

I guarantee the accuracy of information given and take full responsibility for the consequences of any omissions or untruthfulness.

I certify that I voluntarily participate in the ceremonies organized by Pretty Profundo.

I understand that shamanic work may include the use of traditional healing plants. I agree to take full responsobility for my own belongings, during and to/from the ceremony.

I resepect the opportunity to the work within myself with plant medicine, which can help with important aspect to both my phsyical and mental well being. I have chosen this path of healing out of my own free will, and understand that the medicine works uniquely to each individual

I understand that Pretty Profundo reserve the right to deny my participation if they deem that it would be unsafe for me, or for any other important reason.

I agree to listen and follow the instructions given Pretty Profundo.

I take full responsibility for any damage that I may cause to the facility that is used for the ceremony.

I also understand that any unknown ailment that I may have is not the responsibility of the facilitators.

To maintain the safety, trust and respect for all participants, I agree to keep this work confidential.

I will not reveal to anyone the identity of those who are participating in the event, this includes maintaining confidentiality for all facilitators, helpers, shamans or healers who are also participating in the ceremony.

I hereby RELEASE, DISCHARGE AND COMMIT NOT TO SUE the event leader, organizers and/or participants for any and all liabilities, claims and demands related to the event.

I agree to participate with the purest intention of heart, promoting the health and wellbeing of all participants. I agree to inform Pretty Profundo regarding Medical condition / intake of medicine / dietary changes 2 weeks prior to the retreat.

Full Name (By Typing your name you agree to use this as a signature)

Date

Your content has been submitted

I understand and agree to everything listed on this Pretty Profundo Pre-Screen Form

Yes