Ceremony Client Intake Form Name* First Last Date of Birth* MM slash DD slash YYYY Gender*GenderMaleFemaleEmail Address* Occupation* City & State of Residence* Medical Condition*Consent* By checking this box I acknowledge that if I am taking any prescription medications that I am responsible for speaking with my doctor about any potential counter indications. I also acknowledge that I am fully responsible for my own decision to work with this Sacred Medicine. And also that I will follow all Ceremonial Rules. I also acknowledge that there are no refunds, as non-refundable expenses are incurred for my stay.*CAPTCHANameThis field is for validation purposes and should be left unchanged.