Member Intake Form | onacoflakearrowhead

Health Declaration

SAFETY FIRST

Please fill out the following health form. Honesty is imperative in order to ensure your safety and the safety of our work. Please note that certain information provided may necessitate making adjustments to protocol and certain conditions may be contraindicated.

First name

Last name

Phone Number

Have you been hospitalized in the last 12 months?

Yes

Do you have any current or past health conditons?

Yes

If yes to either of the above question, please elaborate

List perscription medication or any, non perscription dietary suppemets, dietaids, sleepaids, herbs or recreational drugs that you currently take or have taken in the past 30 days. Please include any entheogens/psychedelics?

Have you experienced any psychological health issues, eg. bipolar, nervous breakdown, psychosis etc?

Any current or past addictions and if so please elaborate.

What is your intention for ceremony?

Typing in your full name here is representative of your electronic signatue

Emergency Contact

I declare that the info I’ve provided is accurate and complete. I agree to release my car keys and cell phone untl four hours after ceremony is closed. And, I willingly agree to go to the ER under the unlikely event that it is necessary.

Thanks for submitting!

Of Lake Arrowhead

Health Declaration