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Spirit Pharmacist Consultation Intake Form

Please complete the following form as completely and truthfully as possible. You will be re-directed to the consultation booking page upon completion of this intake form. 
37Questions

HIPAA

Compliance

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    You must supply a working email address for consultation service
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    If you check the box below, the email address supplied will be added to Spirit Pharmacists' mailing list
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    Please use the following to select a contact method. International consultation will take place via Zoom.
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    Please complete with phone number including area code
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    • Male
    • Female
    • Other
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    Please select all that apply and describe further in the next page of the form
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    Please use this space to FURTHER DESCRIBE medical conditions from the previous page. Information on how active or bothersome it is, how acute (urgent/emergent) it is, how severe it is etc. is welcome.
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    Please select all that apply and describe further below. f you do not have any of the psychiatric conditions listed please select 'none of the above'.
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    Pleas use this space to describe any psychiatric condition you have further here
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    If yes please describe further below
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    If yes please describe further below
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    Please include a complete list of your prescription medications including the drug NAME, DOSE, and FREQUENCY of use. Inclusion of any notes on effectiveness, side effects, or other desires and intentions regarding their use is welcome.
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    Please include a complete list of your OTC medication, supplements, and herbal products including the NAME, DOSE, and FREQUENCY of use. Inclusion of any notes on effectiveness, side effects, or other desires and intentions regarding their use is welcome.
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    Please select the option that most closely matches your use
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    What kind of tobacco product to you use? how often? for how long?
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    If you have not used any please mark 'none of the above'
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    How much of each substance? How often? Any additional commentary you wish to offer.
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    Psilocybin mushrooms, LSD, ayahuasca, DMT, MDMA, ketamine, ibogaine, mescaline etc.
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    Please describe the use and experiences with previous psychedelics.
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    Please list psychedelics you may be interested in using or are hoping to learn more information about
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    Please use this space to type any specific questions you may have either about your medications or psychedelics as well as what you're hoping to gain from your consultation most
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