Apply for Iboga Treatment Patient Information Form Apply for Ibogaine Treatment To apply for ibogaine treatment, please fill out and submit the Patient Information Form. Name Email Date of birth Weight Height Phone Number Country Language Gender Male Female Do you drink alcohol or smoke tobacco? * Yes No What is your preferred method of communication? Text Message Email WhatsApp Phone Call List any current medical problems & allergies Upload A medical Report Please list any current medications List any past surgeries Description of substance use or Addictions Send
