Name *

First Name

Last Name

Phone *

(###)

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Phone *

(###)

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Participants Date of Birth *

MM

DD

YYYY

Which of these are currently applicable to you? (Make bold, please elaborate below)

use of MAOI’s / SSRI’s / SNRI’s. If you don’t know what these are, then this is probably not applicable to you ;-).

heart conditions or serious cardiovascular problems,

liver problems / use of medications that are heavy on the liver (e.g. low dose chemo)

auto-immune disease

family history of schizophrenia or early onset mental illness,

seizures / epilepsy malignant hypothermia or other types of susceptibility to heat stroke