Sacred Medicine Form

Which Ceremony are you applying for?

AYAHUASCA

BUFO

HONGUITOS

KAMBO

TABACO

CACAO

OTHER

Do you have a past history of, or currently suffer from any of the following?

Cardiovascular disease, including heart attacks

High / low Blood Pressure

Mental illness

Recent surgery

Past or recent physical injuries (fractures or dislocations)

Glaucoma

Retinal detachment

Infectious or communicable diseases

Epilepsy

Asthma

Diabetes

Schizophrenia

Bipolar

None of the above

other

Do you have any issues with the following listed below?

Head / neck

Eyes, ears, nose or throat

Lungs

Skin

Intestines /bowels / digestion

Back

Bladder or kidneys

Liver

Chest / heart

Circulation

Sleep disorder

None of the above

other

Are you taking any of the following medications:

Paxil

Welbutrin (bupropion)

Zyban

Pristiq

Cymbalta

Ixel

Effexo

Tramadol

Tramal

Ultram

Sibutramine

Meridia

Reductil

Axiomin

Etonin

Lubazodone

Serzone

Nefadar

Trazodone

Desyrel

Strattera

Edronax

Vivalan

Focalin

Ritalin

Concerta

Adderall

Dexedrine

Desoxyn

Vyvanse

Elavil

Endep

Evadene

Clomipramine

Anafranil

Desipramine (Norpramin, Pertofrane)

Amoxapine (Asendin)

Maprotiline (Ludiomil)

Mianserin (Bolvidon, Norval, Tolvon)

Mirtazapine (Remeron)

Isocarboxazid (Marplan)

Moclobemide (Aurorix, Manerix)

Phenelzine (Nardil)

Pirlindole (Pirazidol)

Selegiline

Eldepryl

Zelapar

Emsam

Tranylcypromine (Parnate)

Lithium

or other

None of the above

Are you pregnant, suspect you are pregnant or are breastfeeding?

Pregnant

Suspect Pregnant

Breast feedign

N/A

Have you taken any recreational or pharmaceutic substances over the past 12 months.

Alcohol

Marijuana

LSD

Vapes

SSRIs

Demerol

Cold medication

Decongestants

Sinus medication

Nasal sprays

Hay fever medications

Diet pills

Amphetamines

MDMA

Ecstasy

Cocaine

Heroine

Crack

Other

None of the above

VITAL-KI SACRED MEDICINE INTAKE, CONSENT & LIABILITY WAIVER I hereby confirm that I have read and fully understood the above information and have answered all the intake medical questions completely and honestly and have not withheld any information. I acknowledge that participation in the Sacred Medicine Ceremony involve discomfort and unexpected physical, mental, or emotional upset. In signing this release document, I agree to waive all rights to seek or receive compensation in case of injury, loss, or damage. I am fully informed of the objectives of the application of this Sacred substance during the ceremony and of its possible effects. Participation in the Sacred Medicine Ceremony includes the application or ingestion of a medicinal substance, or an entheogen and I am informed of the objectives of ingesting this Sacred Medicine during the ceremony and of its possible effects. I choose to attend this holistic work as a result of my research and interest in ceremonies. I understand that my participation in this ceremony is entirely voluntary, and I agree to remain at the ceremony to its completion. I accept that the ceremony shaman, leaders and helpers make NO claim or promise about the curing of illness of any kind, or about the nature of any spiritual experience which I understand is entirely personal. I understand that my participation in the ceremony may be physically, mentally, emotionally, or spiritually demanding. I understand that I may experience dizziness, nausea, vomiting, diarrhea or other physical upsets. I accept full responsibility for anything that may occur including emotional disturbance, mental disorientation and any and all possible manifestations of physical, emotional and mental changes. I acknowledge that I am aware of the risks and potential benefits of my participation, and I freely choose to enter this process, accepting full responsibility for whatever may occur whether anticipated or unanticipated. I understand that the use of any drugs or prescribed medication may interfere or have an adverse effect if ingested prior to, during or after the ceremony. I acknowledge that the proper dietary guidelines have been provided to me and I take full responsibility for adhering to those guidelines. I acknowledge that, I will make alternate arrangements for transportation in the event that I may be physically or mentally exhausted and/or disoriented after the ceremony. I am informed of the nature of the Sacred Medicine Ceremony, the needed preparation, and the rules of the Sacred Medicine Ceremony. I commit myself to stay in the circle until the end of the ceremony and to respect the directives given by the organizers, helpers, and facilitators(s) of the ceremony. I hereby attest that I am not ingesting any drugs or medication at this time. I hereby knowingly and voluntarily assume the full risks of any physical or moral injury, damage, or losses, either to myself or caused to others by me during this sacred ceremony. I hereby waive the liability of and agree to hold harmless any of Vital-Ki staff, the shaman, facilitators and all of the helpers, associates, employees, agents, staff, family successors, volunteers and other participants. I further agree to defend and indemnify them from any claims, suits and demands. This agreement is binding upon myself, my spouse, parents, family, heirs, executors, administrators, agents and assigns. PAYMENT POLICY: Energy Exchange: as agreed, to be paid in full at the time of application. I fully understand that disrespectful or abusive behaviour will not be tolerated under any circumstances. CANCELLATION POLICY: No refunds will be given 7 days prior to the event. *No refunds will be given for missing or not showing up. 50% of the monies can be used for future Vital Ki events if there is an unforeseen circumstance and you cannot attend the ceremony. I HAVE READ, AND FULLY UNDERSTAND AND TAKEN TIME TO CONSIDER THE INTAKE-FORM. AND I FULLY UNDERSTAND AND TAKEN TIME TO CONSIDER THIS WAIVER. I SIGN THIS AGREEMENT VOLUNTARILY

I HAVE READ, AND FULLY UNDERSTAND AND TAKEN TIME TO CONSIDER THE INTAKE & WAIVER FORM. I confirm that the information giving by me is TRUE. THEREFORE, I AGREE with the terms and conditions of the above SACRED MEDICINE INTAKE, CONSENT & LIABILITY WAVER FORM. I am fully AWARE of what I am embanking in this Ceremony. I will read all the additional information given and fully prepare for Ceremony. I am signing this form full AWARE and VOLUNTARILY.

Amazing Feature

Sacred Medicine Intake & Waiver Form