9 day 4 San Pedro ceremonies – Auzangate Visit – retreat in the Sacred Valley, Peru. Aug 16, 2025

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1 Participant details

2 Welcome

3 Participant Info

Birth Date *
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Street Address *
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Emergency Contact Name *
Emergency contact - relationship to you *
Emergency contact - Phone, including country code *
Emergency contact - Email *

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4 Medical Screen

	Important: The use of plant medicines is contraindicated with certain medical conditions and medications. Your safety and well-being are our primary concern. In order to ensure this, it is important that you disclose all relevant medical conditions that you have been diagnosed with or experience, as well as all medications, supplements or drugs you are currently taking or have taken in the past. All information you provide is confidential and is collected to assess risk and ensure that you are properly prepared for the sacred plant retreat.
*	I understand and agree
Have you been diagnosed with or do you experience any of the following: *	Diabetes Physical disability Mobility issues Epilepsy / Seizures Dizziness, fainting or blackouts Autoimmune condition Thyroid condition Pulmonary (lung) problems Asthma Obesity Infectious diseases Hernia Chronic pain None of the above
If so please provide details (diagnostic history, hospitalizations, the stability of the condition and any medications you take including details of dosages, frequency and timing). *	If not applicable please write 'NA’.
Do you experience, have a history of or have you been diagnosed with any of the following: *	Bipolar Disorder Schizophrenia Dissociative Identity Disorder (DID) Psychotic episode(s) Borderline Personality Disorder (BPD) ADD / ADHD Anxiety Panic attacks or Panic disorder Phobias Obsessive Compulsive Disorder (OCD) Depersonalisation / Derealisation Excessive rumination or worry Persistent agitation or unease Depression Suicidal thoughts or ideation Cutting or self harm Persistent low mood or lethargy Eating disorder Alcohol or Drug addiction Chronic insomnia Paranoia Uncontrollable rage / anger None of the above
If so please provide details (diagnostic history, hospitalizations, the stability of the condition and any medications you take including details of dosages, frequency and timing). *	If not applicable please write 'NA’.
Do you experience, have a history of or have you been diagnosed with any of the following: *	Angina High Blood Pressure Heart disease Heart attack Heart surgery, including stent or pacemaker Abnormal heartbeat Stroke Aneurysm Breathlessness without exertion Chest pain or discomfort with exertion None of the above
If so please provide details (diagnostic history, hospitalizations, the stability of the condition and any medications you take including details of dosages, frequency and timing). *	If not applicable please write 'NA’.
Do you have any serious or life threatening allergies? *	Yes No
If so please provide details (diagnostic history, hospitalizations, the stability of the condition and any medications you take including details of dosages, frequency and timing). *	If not applicable please write 'NA’.
Do these allergies require the use of an Epipen?	Yes No
If 'Yes' please confirm that you will be bringing an Epipen with you to the retreat	Yes No
Have you sustained any recent injuries? *	Yes No
If so please provide details (diagnostic history, hospitalizations, the stability of the condition and any medications you take including details of dosages, frequency and timing). *	If not applicable please write 'NA’.
Have you had any surgeries or major accidents that you haven’t already mentioned? *	Yes No
If so please provide details (diagnostic history, hospitalizations, the stability of the condition and any medications you take including details of dosages, frequency and timing). *	If not applicable please write 'NA’.
Have you experienced a significant trauma? (ie abuse, attack, violence, accident, loss of a loved one) *	Yes No
If so please provide details. *	If not applicable please write 'NA'
Are you Pregnant? *	Yes No Not applicable
Do you have any other medical or health conditions not listed above? *	Yes No
If so please provide details (diagnostic history, hospitalizations, the stability of the condition and any medications you take including details of dosages, frequency and timing). *	If not applicable please write 'NA’.
Do you have a family medical history of any of the following? *	Diabetes Epilepsy / Seizures Dizziness, fainting or blackouts Autoimmune condition Thyroid condition Pulmonary (lung) problems Asthma Obesity Infectious diseases Hernia Chronic pain Bipolar Schizophrenia Dissociative Identity Disorder (DID) Psychotic episode(s) Borderline Personality Disorder (BPD) ADD / ADHD Anxiety Panic attacks or Panic disorder Obsessive Compulsive Disorder (OCD) Depersonalisation / Derealisation Depression Self harm Alcohol and drug addiction Paranoia Uncontrollable Rage / Anger Angina High Blood Pressure Heart Attack Heart Disease Heart Surgery Abnormal heartbeat Stroke Aneurysm No I do not
If so please provide details. *	If not applicable please write 'NA'

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5 Medications, Supplements and Drugs

Please list any pharmaceutical medications you are currently taking including dosage, frequency and time you take them. *	If not applicable please write 'NA'
Please list any pharmaceutical medications you have taken in the past, how long you took them for and when you stopped taking them. *	If not applicable please write 'NA'
Please list any herb, vitamins or supplements you are currently taking or have taken in the past month. *	If not applicable please write 'NA'
Please list any recreational drugs you currently use and how often you use them. *	If not applicable please write 'NA'
Please list any recreational drugs you have used in the past, how long you used them for and when you stopped using them. *	If not applicable please write 'NA'

6 Acknowledgement

Important:	I understand that Samadi Healing has collected this information for the express purpose of assessing risk and optimising my safety and well-being. I attest that I have fully and truthfully disclosed all requested medical information and facts. I further understand that by omitting or falsifying relevant information I may be putting myself at risk and accept full responsibility for my actions.
*	I understand and agree

7 Plant Medicine Experience

Have you used plant medicines in the past? (Ayahuasca, Psilocybin mushrooms, Peyote, San Pedro etc. *	Yes No
If so where, when, with whom and on how many occasions?
What were the results?
What is your primary motivation for ingesting sacred plants?	Physical healing Psychological healing Emotional healing Behavioural change Personal growth and development Spiritual exploration Personal exploration
Is there anything else you would like us to know about yourself or your reasons for ingesting sacred plants?

8 Accomodation

If you've elected to share a room with a friend or partner please provide their name

9 Food

Do you have any food allergies, intolerances or preferences you’d like is to know about?	Yes No
If so please provide details

10 Restrictions and Guidelines

Important:	Sacred plants can have a powerful impact on your body and mind. In the days and weeks before the retreat, during the retreat and after the retreat certain restrictions need to be observed. Adhering to these restrictions will ensure your safety and wellbeing, as well as a positive sacred plant experience. Drugs and Alcohol Recreational drugs and alcohol are prohibited for 14 days before the retreat, during the retreat and for 7 days after the day of your last ceremony. Please be informed that consuming alcohol or recreational drugs directly following a plant medicine ceremony or retreat can be extremely dangerous, and can potentially lead to psychological problems. Sex Sex or sexual activities of any kind (including masturbation) are not permitted during the retreat and for 3 days after the day of your last ceremony. Medications and supplements There are certain pharmaceutical medications that are contraindicated for sacred plants and our shaman will discuss these with you. You are not permitted to take these medications prior to the retreat, during the retreat, and for at least 3 days after the day of your last ceremony. If you need to take any new medications in the 3 days following the ceremony, please contact us to ensure they are compatible with San Pedro. The use of vitamins and minerals after the retreat is permitted. Sugar You should not consume processed sugar, sugar-laden foods or artificial sweeteners for 3 full days before the retreat, during the retreat and for 3 days after the day of your last ceremony. Fruits and fruit juices are acceptable in moderation. Meat Do not consume meats that might contain violent or skittish energies for at least 14 full days before the first day of the retreat. Examples include: Rabbit, Pork, Deer, Aligator, Pirana, Shark, and Duck. ___________________________ The reasons for these restrictions will be explained to you by one of our staff members at the commencement of the retreat. Should you have any questions or concerns please don't hesitate to discuss them with us.)
*	I have read and understood the guidelines and restrictions and agree to abide by them.

Important:

Sacred plants can have a powerful impact on your body and mind.

In the days and weeks before the retreat, during the retreat and after the retreat certain restrictions need to be observed. Adhering to these restrictions will ensure your safety and wellbeing, as well as a positive sacred plant experience.

Drugs and Alcohol
Recreational drugs and alcohol are prohibited for 14 days before the retreat, during the retreat and for 7 days after the day of your last ceremony. Please be informed that consuming alcohol or recreational drugs directly following a plant medicine ceremony or retreat can be extremely dangerous, and can potentially lead to psychological problems.

Sex
Sex or sexual activities of any kind (including masturbation) are not permitted during the retreat and for 3 days after the day of your last ceremony.

Medications and supplements
There are certain pharmaceutical medications that are contraindicated for sacred plants and our shaman will discuss these with you. You are not permitted to take these medications prior to the retreat, during the retreat, and for at least 3 days after the day of your last ceremony. If you need to take any new medications in the 3 days following the ceremony, please contact us to ensure they are compatible with San Pedro. The use of vitamins and minerals after the retreat is permitted.

Sugar
You should not consume processed sugar, sugar-laden foods or artificial sweeteners for 3 full days before the retreat, during the retreat and for 3 days after the day of your last ceremony. Fruits and fruit juices are acceptable in moderation.

Meat
Do not consume meats that might contain violent or skittish energies for at least 14 full days before the first day of the retreat. Examples include: Rabbit, Pork, Deer, Aligator, Pirana, Shark, and Duck.
___________________________

The reasons for these restrictions will be explained to you by one of our staff members at the commencement of the retreat. Should you have any questions or concerns please don't hesitate to discuss them with us.)

I have read and understood the guidelines and restrictions and agree to abide by them.

Continue

11 Referral

How did you hear about us? *	From a friend or retreat participant Web search Facebook or Other social media
Friend or participant's name
After your registration, you will be directed to book a discovery call with us. This step is part of your registration process. Please choose a time and date for your call where we can meet each other in person and go over your registration form to cover any necessary questions. *	I understand and agree

12 Donate

$	Support more by donating A big part of the income at Samadi Healing is being accumulated to support the creation of a healing center. Your donation is contributing to manifesting this dream.

13 Security Check

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14 Payment

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