Participant Registration Form

Contact information

17%

Language:

English

Casa de Pawua Patient Registration Form

To ensure a safe and nurturing stay with us free of any unnecessary risks, it is crucial that you complete this form with honesty.

Patient information

Name

Email

Nationality

Birthday

DD

/

MM

/

YYYY

Emergency Contact Name

Emergency Contact Phone (including country code)

Date of arrival

MM

/

DD

/

YYYY

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Plant medicine experience

33%

Language:

English

Casa de Pawua Patient Registration Form

To ensure a safe and nurturing stay with us free of any unnecessary risks, it is crucial that you complete this form with honesty.

Plant medicine experience

Introducing plant medicine shamanism into your life can accelerate both healing and personal growth. However it is a journey, a process, and not a quick fix. The experience can be cathartic as well as confronting and challenging. Out of respect for the ancient practices we honor and for your healing to be as efficient as possible, we ask that you carefully consider your intention for undertaking this journey and that if you decide to proceed with it, that you do so with full commitment, which includes sticking to a strict diet and other protocols Maestro Niño provides such as staying in solitude and silent introspection for varying lengths of time though it may be tough.

Please explain why you are looking to come stay with us (100 words minimum):

What treatment you are interested in (select all that apply):

Ayahuasca ceremony

Tobacco ceremony

Chall'a ceremony

Master/ Teacher plant dieta

Treatment using other medicinal plants

Have you drunk ayahuasca before?

Yes

No

Do you have experience with other visionary plant medicines or psychedelics? Please explain:

Meat-eater

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Physical and mental health history

50%

Language:

English

Casa de Pawua Patient Registration Form

To ensure a safe and nurturing stay with us free of any unnecessary risks, it is crucial that you complete this form with honesty.

Physical and mental health history

It is necessary that you agree to disclose, in confidence, any known medical conditions and/or use of any medication. By coming to Casa de Pawua, you are declaring that you are in a physical and mental condition appropriate to the activities described in the treatments, and agree that you participate at your own risk and that we cannot accept liability for any accident or injury. You should seek professional medical advice on preparations. We need to offer this advice and insist on these conditions in order to assure your personal safety and the overall safety and welfare of our patients and team.

Although ayahuasca has not been found to cause psychosis or other psychiatric disturbances, it can be dangerous to those with a history of psychological problems. Please tell us, in confidence, about any history of mental health problems. If you have a heart condition or chronic high blood pressure you may not be able to drink ayahuasca. It is not safe to drink ayahuasca when you are pregnant. Special note to diabetics: MAOIs may change the amount of insulin or oral anti-diabetic medication that you need. If you are diabetic or have high blood pressure please provide more information in the section "Is there anything else about your physical or mental health we should know about?" for us to closer discuss your particular case. There is a chance that you may not be able to drink ayahuasca but instead receive treatment from other plants focused on treating these conditions.

Please indicate if any of the following conditions apply to you:

High or low blood pressure

Cardiovascular disease including history of heart attack and/or stroke

Irregular heartbeat

Epilepsy

Obesity

Any mental disorder

Any physical disability

Depression

Bipolar disorder

Schizofrenia

Suicidal thoughts

Autism

ADHD

Anxiety disorder

Visual impairment

OCD

Recent surgery

Asthma

Diabetes (Type 1 or 2)

Any recent or current infectious or communicable diseases

Past or present physical injuries (fractures or dislocations)

Insomnia

Addiction (alcohol, prescription medication, "street drugs" etc.)

History of seizures

History of fainting

Other

None of the above

Please list any allergies:

Are you currently pregnant?

Yes

No

Please indicate if any of the following pertain to you:

- Have you ever been hospitalized for medical or psychiatric reasons?
- Do you have any history whatsoever of psychosis, schizophrenia, hallucinations, or bipolar diagnosis?
- Are you currently in therapy or involved in any type of support group?

If your answer is “yes” to any of the above, please elaborate.

Is there anything else about your physical or emotional health that we should be aware of?

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Medication history

67%

Language:

English

Casa de Pawua Patient Registration Form

To ensure a safe and nurturing stay with us free of any unnecessary risks, it is crucial that you complete this form with honesty.

Medication history

Certain drugs and medications have been found to not be compatible with ayahuasca. It is essential to stop taking the following substances, and give your system sufficient time to remove them from the body, before you begin a treatment with us. Please consult your doctor if you are in any doubts, you certainly should not suddenly stop taking prescribed medications (including antidepressants) without consulting your doctor.It is not safe to work with ayahuasca if you take the following medications or have any of the following health conditions: any medication that contains Monoamine oxidase inhibitors (MAOI’s). These medications are known to cause dangerous side effects when taken in conjunction with ayahuasca. It is critical that you stop taking these drugs and allow plenty of time for your system to be cleared of these substances. Any medication which has an effect on the serotonin system, including Selective Serotonin Reuptake Inhibitors (SSRIs) (i.e. antidepressants such as Wellbutrin, Prozac, Zoloft, Effexor, etc). Combining these medications with ayahuasca can induce serotonin syndrome – far more severely than with foods containing tryptophan, and with potentially fatal results. We advise you to stop taking SSRI medications four weeks prior to a program to allow the system to clear in time; some of these drugs may cause side effects when you stop taking them, and you should allow plenty of time for these to subside. You should not abruptly stop taking them without discussing the matter with your doctor. Please note that the herbal antidepressant St. John’s Wort (Hypericum Perforatum) also must not be taken directly prior to working with ayahuasca, although the system can clear this in 2 weeks before commencing a retreat. Other medications you must suspend taking are decongestants, cold medications, allergy medications, antihistamines, sedatives, tranquillizers, amphetamines (including Adderall), some hypertensive medications, sympathomimetic amines including pseudoephedrine and ephedrine, carbamazipine, methylphemidate (Ritalin), macromerine, phenelanine, tyrosine, tryptophan, asarone/calamus, asthma inhalers and diet pills.For the next four questions, please note that it is imperative that you provide an accurate and detailed list of medications, supplements and recreational drug intake as the plant medicine can dramatically increase the effects of certain substances to the point of becoming dangerous. Please note that all medications will need to be discontinued prior to arriving at Casa de Pawua for treatment with plant medicine, and if applicable, we recommend seeking advice from your doctor how to taper off medication safely.

Are you currently taking ANY type of pharmaceutical medications, over-the-counter medication, prescription medication, vitamins, herbs or supplements?

Please also indicate if you have ever taken tranquilizing medications, SSRIs or any other antidepressant medication?

If “yes” to any of the above, please list all medications including dosage and frequency taken and for how long.

List any recreational substances that you have taken over the past 12 months (alcohol, "street drugs"). Please include frequency of use.

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Terms of Service

83%

Language:

English

Casa de Pawua Patient Registration Form

To ensure a safe and nurturing stay with us free of any unnecessary risks, it is crucial that you complete this form with honesty.

Terms of Service

I agree to the terms of service.

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Pacient Agreement

100%

Language:

English

Casa de Pawua Patient Registration Form

To ensure a safe and nurturing stay with us free of any unnecessary risks, it is crucial that you complete this form with honesty.

By coming to Casa de Pawua, all guests agree to the following policies, guidelines and waivers:

- Patient understands that no returns or refunds are available once payment has been made for any reason.

- Patients voluntarily enter into a shamanic treatment with Maestro Nino, which may include a series of plant-based treatments including Ayahuasca

- No patient will be forced, coerced or pressured into taking Ayahuasca or any other treatment they are not comfortable with.

- Patient agrees to cease any supplemental treatment during their period of stay at Casa de Pawua, and follow Maestro Nino’s recommended protocol to the best of their ability.

- Patient understands that Casa de Pawua makes no claim or guarantee of healing or curing, and patient releases Casa de Pawua from responsibility (legal and otherwise) of any and all adverse effects guest may experience.

- It is the patient's responsibility to adequately research plant-based shamanic treatment, including Ayahuasca, and fully read and follow Casa de Pawua's Preparation and Medical Precautions pages.

- Patient agrees to fully disclose any addictions, psychiatric diagnoses, communicable diseases, special needs and other relevant medical history.

- All personal information that the patient discloses to Casa de Pawua will be kept confidential and will only be shared with relevant Casa de Pawua staff.

- Patient agrees to honor and respect all Ashaninka traditions introduced at Casa de Pawua and refrain from attempting to change or disparage these traditions when communicating with other guests.

I hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly in the "Patient Registration" form which includes: "Contact information", "Plant medicine experience", "Physical and mental health" and "Medication history" and have not withheld any information. I also confirm that I have read, understood, and accept the "Patient Agreement" and "Terms & Conditions."

Signature

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20