BOOKING FORM

Emergency Contact

I confirm my emergency contact is aware , I will be travelling to Peru to attend an Ayahuasca Lux retreat, should they need to be contacted.

Are you travelling with someone

**Note**: Shared Rooms automatically accommodate people of the same gender together. If you are booking with someone of the same gender, please indicate this here so we can confirm if you are in the same room (depending on availability - not guaranteed). If you are requesting a roommate of a different gender in a Shared Room, please contact us. Please have both parties indicate the other person in the request. If you are coming with a partner, select the room you may like below (depending on availability - not guaranteed) and indicate the name of your partner.

Would you like to book a shared or single room?

If booking a single room, please select the room

Dietary Needs & Allergies

What are your intentions for attending the retreat?

Have you ever taken Psychedelics?

Have you ever taken Ayahuasca?

Have you ever had bad trips? If so, how many / how often?

Please select any physical health conditions you are experiencing right now or have experienced in the past:

Please indicate any other physical health condition that you are currently experiencing or have experienced in the past.

Have you ever had major surgery of any kind? If yes, what kind of surgery and when did it take place?

Please select any mental conditions you are experiencing right now or have experienced in the past:

Is there any history in your immediate family of the psychological/psychiatric conditions mentioned above? If yes, Please provide more information. What conditions effects/effected which family members.

Please list any other psychological/psychiatric information not listed above:

Are you allergic to any medication? Please list them if any.

Please list any recreational substances you have taken over the last 6 months. Including alcohol and canabis. Please include frequency of use.

Have you ever been diagnosed with, or treated for a drug or addiction?

Are you currently taking or have you recently stopped taking (within the past month) any natural supplements, herbal medicines, or vitamins (including St. John wort, 5-HTP, Kava etc.)? please list them if any.

Is there anything additional regarding your health history that you feel we should know?

Other Comments or Special Needs

How did you hear about us?

Booking agreement

I understand that my registration is not confirmed until my application has been reviewed and approved by AYAHUASCA LUX and until I have paid my deposit.

Terms & Conditions

I accept the full Terms and conditions (click to read). I have read and will sign upon arrival the safety waiver and release form and attest that all information is accurate and accept full legal & personal liability for joining this retreat, protecting AYAHUASCA LUX from all legal liability.

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