Intake formulier

Important: fill in the intake form

We are glad you found your way to plant medicine.

In this form, we ask information about known medical conditions and/or the use of prescription drugs or medication (if applicable). We screen participation per registration. That is why we ask you to fill in the questionnaire as truthfully and as accurately as possible.

Your registration is final after returning the completed intake form; when we are sure whether you can participate in the ceremony. And after the (down) payment.

*Naturally we treat shared information confidentially.

 

Voor- en achternaam / First- and family name
DD slash MM slash YYYY
(Required)