INTAKE FORM:

Full Name

Email *

Phone *

Date Of Birth

Address

Emergency Contact (Name and Number)

CEREMONY DETAILS:

Intention for Ceremony

Preferred setting for Ceremony. Via Zoom or In person?

Have you experienced a psychedelic journey? If so, please list the medicines and approximate dates below.

Any Specific Concerns regarding the Ceremony?

Do you have a preference on strains?

Sativa

Indica

Hybrid

Do you understand you must bring your own Cannabis to the Ceremony?

MEDICAL HISTORY:

Any Known Medical Conditions (Mental and Physical)

List Current Medications and Allergies

Have you experienced, anxiety, depression, or panic attacks in the last 30 days?

What is your Previous Experience with Cannabis?

ADDITIONAL INFO:

Any Additional Comments, Questions Or Special Requests?

I agree to terms & conditions provided by the company and understand that this is a waiver and acknowledge I am responsible for my participation on this ceremony and I hereby release The Blooming Lotus Healing and all who operate for this company from any responsibility regarding my participation. By providing my phone number, I agree to receive text messages from the business.