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Apply

The IbogaQuest application will help us determine your needs, how to best serve you, and assess the time and costs of ibogaine treatment for your specific situation. It will also help us address any concerns you have about the ibogaine experience.

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Please answer the questions openly, honestly and in as much detail as you feel comfortable sharing. The more information we have, the better we can serve you.

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We hold your information in the strictest confidentiality. We will never sell your information to a third party for any reason, period. And the only time we share your information is for collaborative purposes with partner treatment facilities, but only after your express written permission.

Gender
Male
Female
Other
Do you have a Passport?
Yes
No
Do you have any current or pending legal issues?
No
Yes
Employment Status
Employed
Unemployed
Self-employed
Are you responsible for children?
Yes
No

We encrypt all form submissions with the latest and strongest SSL encryption. Our site is also behind a security firewall ensuring that your data is transmitted to us and us only.

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To comply with the European Union based GDPR privacy legislation, as well as because we think you should be in charge of your data anywhere in the world you are, if at anytime you wish us to delete your information from our servers, please contact us and we will do so promptly.

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