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Patient Application

    Last Name*

    Date of Birth*

    City* Province*

    Postal Code*

    Email Address
    Phone Number

    Are you currently working with a therapist?*

    Do you currently have a family physician?*

    What is the underlying reason(s) for applying?*
    Please list one or more of the following that applies:

    Briefly describe further the reasons you would like to apply for psilocybin therapy. *

    I confirm that I have not been diagnosed with Schizophrenia, Borderline Personality Disorder, or Bipolar Disorder.*

    I confirm that I am not experiencing any active uncontrolled medical conditions that may be incompatible with safe exposure to psilocybin. (unstable angina, unstable diabetes, uncontrolled asthma/COPD)*

    I confirm that I have read and accepted Rejuva's Privacy and Terms.*