General Inquiry Form for Services

Thank you from The Pearl Psychedelic Institute for your interest in our services. Once you submit your application, you will be contacted for scheduling. Please note that by completing this application, you are willingly sharing Protected Health Information (PHI) with The Pearl. The Pearl is not responsible for any potential data breach related to the sharing of this Protected Health Information.

Date

Patient Info

First name

Last name

Email

Which services are you requesting?

Phone Number

Date of Birth

Month

Day

Year

Country/Region

Address

City

Zip / Postal code

Patient Medical Info

Height (inches)

Weight (pounds)

List ALL allergies (medical, food, environmental, etc.)

Have you ever been diagnosed or suspect you have any of the following conditions?

If you checked any of the above conditions, or other, please describe.

List ALL current medications, including supplements

Have you ever been diagnosed or suspect you suffer from any of the following psychiatric conditions?

If you checked any of the above conditions, or other, please describe.

Have you ever been hospitalized for a psychiatric reason

Yes

No

If you answered yes to the above question, please describe.

Do you have suicidal thoughts or have you made a suicide attempt?

Yes

No

If you answered yes to the above question, please describe.

History of Motion Sickness?

Yes

No

Insurance Provider (please provide individual and group numbers. Please know we will needs images of the front and back of your card with intake forms.)

If you require accessibility accommodations, please detail below.