432166e3-f752-4a13-a9d6-2d77f699fa26.jfif

BUFO / 5-MEO-DMT PARTICIPANT WAIVER &
INFORMED CONSENT

This document is intended to ensure that you are fully informed about the nature of the experience,
associated risks, and your responsibilities as a participant. Please read this document carefully and
ask any questions prior to signing.

First name

Last name

Phone

Date Of Birth

Year

Month

Day

Home Address

Emergency Contact Name

Emergency Contact Phone

Relationship to Emergency Contact

There have been no significant changes to my physical health.

There have been no significant changes to my mental health

I am not currently under the influence of alcohol, cannabis, or any non-disclosed substance that

may impair my ability to provide informed consent

If any changes have occurred since completing the screening form, please provide details below:

Informed Consent

Bufo (5-MeO-DMT) is a powerful psycho-spiritual substance that may produce profound alterations

in consciousness, perception, emotions, and sense of self.

Experiences vary widely and no specific outcome can be guaranteed. No specific outcome, benefit,

healing, insight, or result has been promised or guaranteed.

Participation may involve intense emotional, psychological, spiritual, or physical experiences.

Challenging experiences may occur.

Participation may involve physical effects including changes in blood pressure, heart rate, breathing patterns, nausea, vomiting, loss of coordination, shaking, or temporary physical discomfort.

Integration and ongoing self-care are important aspects of this work.

Participation is voluntary and participants may withdraw prior to the administration of medicine.

This experience is not intended to diagnose, treat, cure, or prevent any medical, psychiatric, orpsychological condition and is not intended to replace medical care, psychiatric care, psychotherapy, crisis intervention, or addiction treatment.

Facilitators are not acting as licensed medical practitioners, psychotherapists, or mental health professionals unless explicitly stated otherwise

I acknowledge and agree to the Informed Consent section above.

Participant Responsibilities

Participants are responsible for determining whether participation is appropriate for them.

Participants remain responsible for their decisions, actions, and personal well-being before, during,and after participation.

Participants are responsible for their own integration and aftercare following the experience.

I acknowledge and agree to the Participant Responsibilities section above.

Confidentiality

Facilitators will make reasonable efforts to maintain confidentiality. However, confidentiality cannot be guaranteed in situations involving immediate risk of harm to self or others, medical emergencies, or where disclosure is otherwise required by law.

I acknowledge and agree to the Confidentiality section above.

Assumption of Risk & Release

Participation involves inherent physical, emotional, psychological, and spiritual risks.

Participants voluntarily accept full responsibility for their decision to participate.

To the fullest extent permitted by applicable law, participants voluntarily assume all risks associated with participation and release and hold harmless the facilitator(s), organizers, staff, venue owners,and affiliated parties from claims, liabilities, damages, injuries, losses, or expenses arising from voluntary participation, except where prohibited by law.

I acknowledge and agree to the Assumption of Risk & Release section above.

Medical Emergency Authorization

In the event of a medical emergency, facilitators may seek emergency medical assistance if reasonably believed necessary for the participant's safety or well-being.

Facilitators may also contact the participant's emergency contact and share information reasonably necessary to support the participant's care and safety.

I authorize emergency medical assistance and emergency contact notification as described above

Declaration

I confirm that I am at least 19 years of age and legally capable of providing informed consent.

I acknowledge that I believe myself to be physically, mentally, and emotionally capable of

participating in this experience

I acknowledge that I have read and reviewed this document, have had the opportunity to ask

questions, understand the potential risks and benefits of participation, and certify that the information provided is accurate and complete.

Participant Name

Participant Signature

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