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IXBALAM
OUR TEMPLE
CONNECT
IXBALAM
OUR TEMPLE
CONNECT
OUR TEMPLE
CONNECT
Name *
Phone
Date of Birth *
Which ones of the following medicines have you worked with before? *
if you do not have experience please mark with NA
Please indicate if you have had or are currently undergoing any physical or psychological treatment
If yes please indicate what kind of surgery and how long ago?
Are you currently taking any medication? Have you been on medication recently? (it's important to inform even of anti-histamine use)
What is your normal blood pressure (high, low, normal)
Do you receive any current treatments? *
Physical, Medical, Psychological
Smoking and drinking *
Do you smoke or drink alcohol?
do you currently use any substances like MDMA, cocaine , ... if yes please indicate which ones and how frequently. indicate other kinds of addictions also please
are there any personal issues that you wish for us to be aware of? please indicate so here

Thank you!

We will be in touch soon, about the further details of the retreat.

yihu.

connect@ixbalam.com

+502 3026 - 8475