WELCOME TO YOUR
REWILD JOURNEY

Date

MM

DD

YYYY

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Do you have any medical conditions, allergies, or physical restrictions we should be aware of? *

Yes

No

Are you currently taking any medications? *

Yes

No

Do you have any food allergies or dietary restrictions? *

Yes

No

Have you ever participated in plant medicine ceremonies or any wellness retreats? *

Yes

No