Santuario Huistin (Pucallpa, Peru) Reservation Request Form

** If you are having trouble submitting the form please email - contact@nullayahuascaeasy.com **

** All information is asked solely to gauge if you are currently able to drink Ayahuasca safely as the Ayahuasca you will drink in ceremony does not mix well with some medications and health issues. We don't share this information with anyone outside of Santuario Huistin staff.**

Santuario Huistin Reservation Request 2024

Basic Info:

Your name

Your email

Do you want a 5 night (3 ceremony) or a 12 night (6 ceremony) retreat?

What is your expected arrival date in Pucallpa? Pucallpa can be reached by plane or bus from Lima where you will likely fly in from and is only an hour or so from Lima by flight or a day by bus.
If you also want transport to and from the retreat (recommended as its 3 hours from Pucallpa by road, boat and walk) then we can pick you up either from the terminal (bus or plane) or your hotel depending on your situation.

Medical Information:

Are you taking any medication for depression/anxiety, heart problems? If so please list them ALL and what they are for.

Are you taking any medications for any other condition that hasn't been mentioned in the above question? If so please list them ALL and what they are for.

Do you have any health issues like diabetes, heart conditions, blood pressure issues, thyroid issues or any other health issue you face? If so please list them.

Do you partake in recreational drugs like Marajuana, Coacine, MDMA or any other? If so please list them. These don't usually restrict you from drinking Ayahuasca but you will need to stop using these in preparation for Ayahuasca to be effective. We'll give you more info on what to remove and what to promote in your preparation for Ayahuasca below.

Are you pregnant at the moment or expect to be when you drink Ayahuasca?

Psychological Information:

Have you ever been committed to a psychiatric hospital?

Have you ever attempted suicide?

Please give us a short description of your psychological state at this time:

Anything else you'd like to tell us or ask?

Feel free to tell us anything else you feel is relevant or if you have a question you'd like to hear our advice on feel free to add it here: