My Medical Information – Two Birds Church

Name(Required)

First Last

Gender(Required)

Male

Female

Other

We assign sleeping arrangements by gender. If you select “Other,” you will stay in the ceremony room, as private rooms are not available.

Birth Date(Required)

Must be 18 years or older to join us in ceremony.

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Email(Required)

Please enter a valid email as we may send notifications on availability to this address

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Phone(Required)

Please enter a valid number as we may send notifications on availability to this number

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Phone(Required)

Please enter a valid number as we may send notifications on availability to this number

Please list your location (City,State) you are traveling from(Required)

City State

How did you discovery Two Birds Church?(Required)

Ex. Google Search, Facebook, Instagram, Reddit, Safeceremonies.com, Word of mouth etc.)

Have you attended any Sunday Services, Outreach, or Virtual Services?(Required)

Are you an active member of the Church?

Have you done a Ceremony with us before?(Required)

Yes

No

No, but I have done a ceremony elsewhere

Do you have any experience with other plant sacraments?(Required)

Please provide details if (Yes) For example, tried low dose mushrooms once, or attended two ayahuasca ceremonies previously.

How often do you do psychedelics or recreational drugs.(Required)

Please provide details if (yes) For example, marijuana every day, or once a month etc.

Are you currently pregnant?(Required)

Yes

No

Not Applicable

Are you Covid vaccinated(Required)

Yes

No

Other

Have you ever been diagnosed with depression, anxiety, schizophrenia, or PTSD?(Required)

Do you now, or have you ever had a dependency?(Required)

Prescription, Nonprescription, Recreational drugs & Alcohol, including marijuana.

Do you have any food allergies we should be aware of when preparing meals?(Required)

Are you currently taking any prescription medications, supplements, or recreational drugs.(Required)

Yes, I am on medication

No, medications or drugs’

Medications currently taking. (List medications, dosage, and how often you take it please, and reason for taking):(Required)

This is very important, please be detailed with the name of the medication as well as dosage and frequency. If you are on contradicting medications it can be seriously fatal, please be honest.

Health Conditions(Required)

Please list any health conditions such as (pregnant, breastfeeding, heart problems of any kind, have high or low blood pressure, have had bypass surgery, or have any type of implant.)

Please tell us a little about what brings you to Two Birds and your Intention for Ceremony(Required)

Spots are limited, so please let us know your reasoning for attending.

Individual Participation Agreement(Required)

Ayahuasca is a deeply personal journey that requires full surrender and individual focus. If attending with a friend or partner, we will separate you as much as possible, and interaction will not be permitted during the ceremony.

I understand that this is an individual journey. I feel personally called and fully prepared to navigate this experience on my own, without external reliance or distraction.

Sleeping Arrangement's.(Required)

Men and women will have separate shared bunk rooms for sleeping to ensure everyone’s comfort and safety. There is also an option to sleep in the ceremony room if preferred.

I understand my sleeping arrangements

Transportation(Required)

Please make sure you have your own means of transportation to the retreat and back. If you are flying in, you are responsible for renting a vehicle, Uber, or ride to the retreat center.

I will provide my own transportation to and from the retreat.

Medication Requirements(Required)

I understand I will need to be off All contradicting medications prior to my ceremony.

Yes, I understand the medication requirements

Medical Disqualification(Required)

I understand that if our medical consultant gives a no-go based on medications, I will be fully refunded. I will wait to make reservations or flights until I receive an OK from the medical consultant at Two Birds. Tickets can not be transferred to other dates or held for future ceremonies.

Yes, I understand the medical disqualification

La Dieta(Required)

I am aware of the Dieta restrictions and will be off any substances the appropriate amount of time to ensure safety (Prescription, Nonprescription, and Recreational drugs including marijuana)

Yes, I am aware of Diet

Bloodpressure(Required)

I agree to have my blood pressure taken before ceremony

Yes, I allow to have my blood pressure taken before ceremony

Safety(Required)

I understand that my Keys & Phone will be locked up for safety before ceremonies and returned the next morning.

Yes, I allow to have my phone & keys taken before ceremonies

Refund Policy(Required)

Any cancelations made within 2 weeks of the start date receive a refund minus the Deposit and CC processing fees cancelations made 2 weeks or fewer from start date can not be refunded. Tickets can not be transferred to other dates or held for future ceremonies.

I agree to the refund policy & the nonrefundable deposit and CC Fee

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Medical Consultation notes

This is for notes from Dr Ben.

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Status