Inquiry Form

* These fields are required

1 Welcome

2 Pick Your Preferred Room

3 Guides

Guest 1		First Name* Last Name* Email* Medical/Mental Concerns*
Guest 1		First Name* Last Name* Email* Medical/Mental Concerns*

After completing this form, emails will be sent to everyone in your group to complete their information.

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4 Participant Info

Address
Address 2
City
State/Prov.
Zip/Postal
Country
Email newsletter	Please send me the email newsletter
How would you like us to follow up? (Select all that apply)	Email Text Message iMessage WhatsApp Signal Phone Call
How did you hear about us?
If 'other,' please specify
Medical/Mental Concerns *	Please provide details of any significant or diagnosed medical or mental health conditions. (Use N/A if none).
Please indicate if you are consuming any drugs, substances, alcohol, and/or medications (including psychiatric/pharmaceutical medications). *
Please specify any pharmaceutical(s) medications you are currently taking.	Include the marketed name of the medication, your dosage, how long you have been taking it, and your level of dependency on a scale from 1 (can stop anytime) to 10 (highly dependent).e.g. Sertraline (Zoloft) - I take 50 mg daily for depression. I've been on it for three years. On the dependency scale, I would rate it as an 8, as I rely heavily on it for my mental well-being. If you are not taking any pharmaceutical(s) enter "NONE."
Could you explain your reasons for using the street drug(s) or pharmaceutical medication(s) you've listed? *	We're interested in understanding the context or purpose behind your usage. e.g. "I take Sertraline for managing my depression and anxiety, as prescribed by my doctor." "I use cannabis mainly for relaxation and to help with sleep, especially after stressful days at work."
Medical Preparation *	I understand and agree that to participate in the retreat, I must safely discontinue all contraindicated drugs, substances, alcohol, and psychiatric medications. The weaning process must generally begin 2-4 weeks or more before the retreat, depending on the specific substance, dosage, duration of use, and guidance provided by the Root & Wisdom medical team.We always recommend weaning or titrating under a qualified medical professional's guidance. If needed, Root & Wisdom can connect you with our medical team for support.
Do you have any pre-existing heart conditions? *
Please provide details, including any diagnoses, treatments, or medications related to your heart health. *	e.g., arrhythmias, heart disease, etc.
Are you willing to have an EKG (Electrocardiogram) performed prior to your arrival and share the results with us for our medical team? *	It is a mandatory requirement for all guests participating in an Iboga ceremony. If you have had an EKG conducted within the last calendar year, you may provide that existing report instead of a new exam.
Having an EKG (Electrocardiogram) done before your arrival is a crucial requirement for participating in our retreat. *	I understand that Root & Wisdom requires this test prior to arrival. For guests with or without pre-existing heart conditions, it is absolutely imperative to have an EKG (Electrocardiogram) completed prior to your arrival at our retreat. We cannot accommodate anyone onsite with known heart conditions without a pre-arrival EKG, due to safety concerns and the potential risk of last-minute disqualification from the retreat, for which refunds are not available. If you find it impossible to obtain an EKG beforehand, please reach out to us immediately at (onboarding@rootandwisdom.com). Our team is dedicated to assisting you in securing this essential test, ensuring your safety and compliance with our health requirements.
Have you ever been diagnosed with any liver conditions or diseases, or have a history of alcoholism? *
Please elaborate on your condition, including any ongoing treatments or medications. *	e.g., hepatitis, cirrhosis, fatty liver disease, etc.
Are you willing to undergo a liver panel test prior to your arrival and share the results with us for review by our licensed medical care provider? *	This test is essential to assess your liver health, ensuring it can safely process Iboga.
For guests with pre-existing liver conditions, completing a liver panel test before your arrival is crucial for your participation in our retreat. *	I understand that Root & Wisdom is unable to accommodate guests onsite with known liver issues without a pre-arrival liver panel due to safety concerns. This is also to avoid the risk of last-minute disqualification from the retreat, in which case refunds are not available. If obtaining a liver panel test beforehand is a challenge for you, please contact us immediately at (onboarding@rootandwisdom.com). Our team is committed to assisting you in arranging this vital test, ensuring both your safety and adherence to our health protocols.
Have you had any previous experiences with psychedelics or plant medicines? If not, please select "None" at the bottom of the list. *	LSD Psilocybin Tepezcohuite Bufo (5-MeO-DMT) DMT (Any other form other than Bufo) Ayahuasca Peyote Mescaline MDMA Ketamine Cannabis Kambo Iboga Ibogaine None Other
Please specify the substance(s)
How would you describe your current level of emotional awareness and understanding? *
How would you rate your current level of engagement with spirituality? *
What motivates you to seek an experience with Iboga? *	Please share your intentions, goals, or personal reasons for choosing to work with Iboga.
Payments do not include the cost of plant medicines. *	I understand that payments made through Retreat Guru do not include the cost of: plant medicine, psychedelics or similar products. There will be no additional charges for this retreat.Supplementary Products Exclusion: Participants acknowledge and agree that these Fees presented and payable pertain solely to Services and Offerings, and will not include the cost of any plant-medicines or similar products (collectively, "Supplementary Products") which may be provided, offered, or distributed by a Commercial User, or any other party, in connection with Services or Offerings. Retreat Guru shall bear no responsibility or liability in connection with any provision, offering, or distribution of Supplementary Products, and is not a party thereto. All capitalized terms used herein shall carry the same meaning as assigned to them in Retreat Guru's Terms of Service.

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5 Energy Exchange

Payments made through Retreat Guru do not include the cost of: plant medicine, psychedelics or similar products
There will be no additional charges for this retreat.

If you choose to pay the retreat fee in full, please note that $1,500 of your payment will be considered the deposit. Should you cancel more than 30 days before the retreat start date, you will receive a full refund minus 50% of the deposit ($750) and the non-refundable $150 medical screening fee. If you cancel within 30 days of the retreat, only the remaining balance is refundable, while the deposit and screening fee will be forfeited.

10% Credit card fee	$0

Sub Total	$0

Taxes	$0

Deposit	$0

Due Now	$0 $0

Choose Payment Option

	Please review and sign the Deposit, Cancellation, and Refund Policy before submitting your deposit or full payment. By making any payment, including the deposit or full balance, you confirm that you have read and signed this policy. All details provided below are included in the Deposit, Cancellation, and Refund Policy. If you need a copy, please email onboarding@rootandwisdom.com. Payment Options: 1. Deposit via Zelle (Preferred) - Recipient Email: deposit@rootandwisdom.com - Amount: $1,500 deposit or full balance Instructions: - Open your banking app or Zelle app. - Select "Send Money with Zelle." - Enter the recipient's email, deposit amount, and a memo with your Retreat Start Date and Full Name (e.g., December 28, 2023, John Doe). - Review and send. 2. Deposit via Bank Wire (Preferred) - Bank Name: JPMorgan Chase Bank, N.A. - Account Number: 587362073 - Routing Number: 021000021 - For International Wires: SWIFT Code: CHASUS33 - Amount:$1,500 deposit or full balance Instructions: - Use your bank's online platform or visit in person. - Select wire transfer and enter the bank details above. - Include a memo with your Retreat Start Date and Full Name (e.g., December 28, 2023, John Doe). - Confirm and send the wire transfer. 3. Deposit via PayPal - Recipient Email: troy@rootandwisdom.com - Amount: $1,500 + 5% fee ($1,575 total) or full balance + 5% fee Instructions: - Open PayPal. - Select "Send" and enter the recipient's email. - Enter the deposit amount and memo with your Retreat Start Date and Full Name (e.g., December 28, 2023, John Doe). - Review and send. 4. Deposit via Bitcoin - BTC Wallet Address: Please email us at deposit@rootandwisdom.com - Amount: $50 test deposit first, followed by $1,450 or full balance Instructions: - Use your BTC wallet or exchange app. - Enter the BTC wallet address and the equivalent amount in BTC. - Add a memo with your Retreat Start Date and Full Name (e.g., December 28, 2023, John Doe). - Review, send, and provide us with the transaction ID. 5. Deposit via Credit Card - Instructions: Please process on this page by choosing "Credit Card" as your payment method above. All credit card transactions are managed through Retreat Guru, and each transaction incurs a 10% (e.g., Deposit of $1,500 x 10% = $1,650). --- Important: For any questions or assistance, feel free to email us at deposit@rootandwisdom.com. Click on the button below and these instructions will be repeated on the next page.

Please review and sign the Deposit, Cancellation, and Refund Policy before submitting your deposit or full payment. By making any payment, including the deposit or full balance, you confirm that you have read and signed this policy. All details provided below are included in the Deposit, Cancellation, and Refund Policy. If you need a copy, please email onboarding@rootandwisdom.com.

Payment Options:

1. Deposit via Zelle (Preferred)
- Recipient Email: deposit@rootandwisdom.com
- Amount: $1,500 deposit or full balance
Instructions:
- Open your banking app or Zelle app.
- Select "Send Money with Zelle."
- Enter the recipient's email, deposit amount, and a memo with your Retreat Start Date and Full Name (e.g., December 28, 2023, John Doe).
- Review and send.

2. Deposit via Bank Wire (Preferred)
- Bank Name: JPMorgan Chase Bank, N.A.
- Account Number: 587362073
- Routing Number: 021000021
- For International Wires: SWIFT Code: CHASUS33
- Amount:$1,500 deposit or full balance
Instructions:
- Use your bank's online platform or visit in person.
- Select wire transfer and enter the bank details above.
- Include a memo with your Retreat Start Date and Full Name (e.g., December 28, 2023, John Doe).
- Confirm and send the wire transfer.

3. Deposit via PayPal
- Recipient Email: troy@rootandwisdom.com
- Amount: $1,500 + 5% fee ($1,575 total) or full balance + 5% fee
Instructions:
- Open PayPal.
- Select "Send" and enter the recipient's email.
- Enter the deposit amount and memo with your Retreat Start Date and Full Name (e.g., December 28, 2023, John Doe).
- Review and send.

4. Deposit via Bitcoin
- BTC Wallet Address: Please email us at deposit@rootandwisdom.com
- Amount: $50 test deposit first, followed by $1,450 or full balance
Instructions:
- Use your BTC wallet or exchange app.
- Enter the BTC wallet address and the equivalent amount in BTC.
- Add a memo with your Retreat Start Date and Full Name (e.g., December 28, 2023, John Doe).
- Review, send, and provide us with the transaction ID.

5. Deposit via Credit Card
- Instructions: Please process on this page by choosing "Credit Card" as your payment method above. All credit card transactions are managed through Retreat Guru, and each transaction incurs a 10% (e.g., Deposit of $1,500 x 10% = $1,650).

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Important:

For any questions or assistance, feel free to email us at deposit@rootandwisdom.com.
Click on the button below and these instructions will be repeated on the next page.

	You will be asked for credit card details in the next step. Click the button below to continue.

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