Screening & Application Form

Welcome to the Whispering Wings Mythical Medicinals screening and application form. This form is for customers who are interested in purchasing strong medicines, especially ibogaine. Please fill out the form below to the best of your ability.

Understanding Your Needs

At Whispering Wings Mythical Medicinals, we aim to connect with customers who prioritize health, safety, and responsible use. Our ideal customer understands the importance of liability waivers, risk assessment, and is committed to their own well-being.

Information Required

To ensure the safe and responsible use of our products, we need to collect specific information from you. Please provide accurate details in the form below. This information includes your name, date of birth, address, phone number, and email address. We also require information regarding your history of heart disease, any psychiatric or neurological conditions, current medications, history of substance abuse, and a brief description of your intentions for working with these medicines.

Agreements & Commitments

By submitting this form, you agree to the following commitments. You are required to sign a liability waiver to proceed. You also agree to use our products at their recommended dosages unless directed by another healthcare professional. Please note that Whispering Wings Mythical Medicinals does not provide medium or large doses of ibogaine and is not qualified to guide or facilitate intensive spiritual journeys.

Begin Application

Begin the application form to start your journey with Whispering Wings Mythical Medicinals.

Fill out form

Name *

Date of Birth *

Address *

Phone *

Email *

History of heart disease *

History of psychiatric neurological conditions *

History of substance abuse *

Are you taking any prescription medications, or have you within the last 3 months or expect to within the next 6 months? *

Briefly describe your intentions for working with these medicines *

Liability waiver: "I understand that Whispering Wings is not a medical facility and does not provide medical, psychiatric, or therapeutic advice. I release Whispering Wings, its affiliates, and my representatives from any liability arising." *

Agreement on dosage: "I agree to use medicines by Whispering Wings only for microdosing purposes, unless I am under the care of a qualified practitioner." *

Agreement ibogaine: "I acknowledge that Whispering Wings does not provide medium or large dosages and is not qualified to guide or facilitate intensive spiritual treatments." *

What Happens Next

After you submit the screening form, our team at Whispering Wings Mythical Medicinals will review your application. If you are approved, we will contact you to provide clearance to begin ordering products. We look forward to assisting you on your journey.