Template Letter In Case Of Emergency

I've put this together after a few people requested I shared the letter absolving any sitters in case of emergency..

So here it is:
(Please feel free to suggest any additions, it's quite basic, I probably haven't covered a few things!)


To whom this may concern,

This letter is to confirm my intention to employ the psychoactive drug ibogaine hydrochloride (an full extract of the root bark from an African shrub, Tabernanthe Iboga)

My goal is to use a total dose of:                   

The current accepted amount needed to achieve therapeutic results (attenuation of acute opiate withdrawal symptoms) is between 15mg/kg and 22mg/kg

This would mean I am taking a total of:       Mg/kg

My name is:

Age/DOB:

Weight:

Height:

Average baseline obs:             Dia/Sys.         Bpm 

Allergies:

Health conditions:

Daily prescribed medications:

Daily recreational drug use:

Ibogaine can prolong qt interval, nausea is also a common side effect, it's important to ensure the pt I properly hydrated, sipping electrolytes and IV saline if nessacary. 

Known contra-indications with ibogaine include (but are not limited to), anti-psychotics, SSR'S and SNRI'S, opiates

'safe' drugs include: Benzodiazepines, Tegretol, Lidocaine and adrenaline 

Attached you will find a graph plotted with obs and all consumed medications including iboga

Finally and most importantly,

I have made an informed decision to use ibogaine to detoxify from opiates, I have not been co-erced or bribed.

I fully absolve any of my 'sitters' of any responsibility in the case of fatality.

These people are:

Printed Name:

Signed: