Ceremony Client Intake Form

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Name*

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Date of Birth*

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Gender*

Email 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.*

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