Eagle's Eye Non-Ordinary Altered-State of Consciousness
Informed Consent Agreement

"Liberating and Enlightening Minds"

This webpage contains the Eagle's Eye Non-Ordinary Altered-State of Consciousness Informed Consent Agreement. This agreement can be submitted online by completing it as instructed below, and then clicking on the "submit" button. As an alternative, the agreement may also be downloaded (by using your web browser's "print" function), printed out and manually filled in. In the latter case, please mail (via postal mail) the completed hardcopy to the address listed at the top of the agreement. You may also wish to retain a completed copy for your records.

Eagle’s Eye Non-Ordinary Altered-State of Consciousness Experience

Informed Consent Agreement for Guided Ketamine Use (V3)

Release of Liability

BEST MEDICINE, INC.

DBA Groking Wholeness

8022 Mays Avenue

Riverview, FL 33578

Section 1. – INTRODUCTION

This informed consent agreement (referred herein as the “the Agreement”) between Best Medicine Inc., (described herein as “the Company") and the individual named in Section 12 below contains information about the use of subanesthetic (low dose) intramuscular injections of ketamine for induction of non-ordinary altered state of consciousness (“the Experience”).

Ketamine has been approved by the FDA for use as an anesthetic agent for decades. It is considered safe and effective enough to be used as a battlefield anesthetic because it does not affect breathing or other automatic functions. It works differently than other anesthetics, in that, rather than inducing an unconscious state, ketamine is a "dissociative" agent. That is, it separates the conscious awareness from the sensory input of the body. In anesthetic doses it also produces amnesia for the event.

However, with the use of subanesthetic doses it becomes a means of raising consciousness, unblocking defenses, and building new neural connections to allow better psychological functioning going forward. Utilizing ketamine in subanesthetic doses is considered an off-label use of ketamine.

By checking off the statements indicated in Section 10 below and signing the Agreement in Section 12, you acknowledge that you understand all the information contained within the Agreement and affirm that you give your consent to the administration of ketamine in the context of a guided non-ordinary altered-state of consciousness experience. Please read the entire Agreement carefully. You may ask questions to any of our qualified providers any time before by contacting them via email or telephone at

Email: eagleseye@grokingwholeness.info

Telephone: 762-218-2663 (during normal business hours).

Your query will be forwarded to one of our qualified licensed professionals who will be in contact with you to answer your questions and concerns before signing the Agreement. You will also have an opportunity to ask questions on the day of the Experience anytime during your private session or during your attendance at a group workshop.

The signed Agreement can also be sent to us via postal mail to the address listed above. All seminars, group workshops and individual sessions are lead, administrated and managed strictly by the Company, its licensed professionals, agents and designees.

Section 2. - ELIGIBILITY FOR KETAMINE EXPERIENCE

The licensed professional, (the "Provider(s)") will perform an evaluation of you and if appropriate, administer ketamine. The Provider(s) will be either a medical doctor, doctor of osteopathic medicine, or certified registered nurse anesthetists, which are permitted to administer ketamine in the state of Florida. The process will involve you filling out your history in advance on the “The Eagle’s Eye Workshop Reservation and Registration Form” (the “Registration”), which will become part of your electronic medical record. In addition to the Registration and the Agreement documents, you may also be asked to fill out additional questionnaires and surveys, before and after, your experience. These are for research purposes and, unless you expressly request that this information be shared, it falls under professional confidentiality and will not be shared with anyone.

Please note that it is strongly advised that anyone with a hyperthyroid (overactive) condition should not take ketamine as it may worsen the condition.

Section 3. - THE FORMAT OF THE EXPERIENCE

An additional second guide(s) (from our trained staff) may also be present, especially for a private session or group workshop.

Your vital signs will be taken and recorded, before and after the experience. That includes heart rate, blood pressure and respiratory rate.

Following the experience, for another one to two hours, the guide(s) will remain with the participant(s). This will allow for sharing, if desired, and to be sure the ketamine dosage has worn off to allow you to leave safely.

DO NOT EXPECT TO DRIVE after the Experience. It is strongly recommended that you not drive for 24 hours. If you must be somewhere else, please arrange for a ride, or we can call an Uber or arrange other transportation for you.

During the ketamine session, in order to ensure your safety and wellbeing, you are requested to 1) comply with direct instructions from the Provider and guides until it is agreed that the session is over, and 2) you will remain at the location of the session until the guides agree that you are ready to leave.

The actual session will last approximately two to three hours (longer in a group workshop setting).

Section 4. - THE EXPERIENCE ITSELF

If you qualify for the off-label use of ketamine, you will be administered an intermuscular injection of ketamine. Intramuscular injection of ketamine takes about 4-5 minutes for the effects to be felt, and the experience will last for 60-90 minutes. Dosage will be measured and controlled by your practicioner as an excessive dosage will induce amnesia and, if that were to occur, you will be unable to remember much from the experience.

Please keep your eyes closed throughout the entire experience. Music will be a part of the experience and will be chosen in advance by your guide.

During your experience you will experience a dream state but you will be able to communicate. For example, if you need to use the bathroom, you can call out or raise your hand. Please do not try to do anything by yourself, as your balance and coordination may be temporarily affected.

To minimize the chance of nausea you should not eat solid food for six hours before the session. Clear liquids in moderation (water, tea, broth) are acceptable to drink.

Adverse events that may occur, include rapid heart rate (tachycardia), double vision, rapid eye movements, elevation of intraocular pressure, nausea, and loss of appetite. These usually occur only at higher doses. Your guide will have medication to calm those reactions if needed. Ondansetron (Zofran), CBD, blood pressure or other medications are also available if needed. Your blood pressure and pulse will be taken before and after the session.

Section 5. - AFTER THE SESSION

It is important to remember that you should not drive or engage in any hazardous activity including operating any machinery for 24 hours after the Experience with ketamine.

It is recommended that as soon as you can, begin to write down what you remember of the experience. Your recollections will be freshest and you will bring back the feelings you have experienced in a powerful way.

If you have a therapist, we encourage you to share your experience with that person. If not, we can recommend some therapists of various types that you can choose from. You are encouraged to work with what you have experienced for at least three months before scheduling another session unless your therapist refers you back sooner.

Section 6. - POTENTIAL FOR KETAMINE ABUSE AND PHYSICAL DEPENDENCE

Ketamine belongs to the same group of chemicals as phencyclidine (AKA "PCP" or "Angel dust"). This group of chemical compounds is called arylcyclohexylamines and is classified as hallucinogens ("psychedelics"). Ketamine is a controlled substance and is subject to Schedule Ill control under the Controlled Substances Act of 1970. Medical evidence regarding the issue of drug abuse and dependence suggests that ketamine abuse potential is equivalent to that of phencyclidine and other hallucinogenic substances. Occasional use has a very low risk for abuse or dependence.

With regard to the potential for misuse of ketamine, "cravings" have been reported by individuals with a history of heavy use of ketamine and other "psychedelic" drugs. In addition, ketamine can have effects on mood, cognition (thinking) and perception that may make some people want to use it repeatedly. Therefore, ketamine should never be used except under the direct supervision of a licensed practitioner who is qualified under state law.

Section 7. - ALTERNATIVE PROCEDURES

No other procedure is available to produce the specific psychedelic effects ketamine has; never the less, other techniques that can alter your state of consciousness include meditation, special breathing techniques, guided imagery, hypnosis and other similar methods. No valid comparison of risks and benefits is available.

The use of ketamine for any of the medical purposes described in the Agreement are not being promoted for either the private session or group workshop experience discussed within the Agreement. These descriptions are purely for informational purposes only.

Section 8. - CONFIDENTIALITY

Your privacy and all experience records will be kept confidential. They will be maintained with the same precautions as ordinary medical records. Only health care providers or their agents involved in your care will have access to information contained in your record and only with your written consent. Privacy and confidentiality of the record will be protected to the extent required by law.

The results of ketamine non-ordinary altered-state experience are subject to research study. Published reports will not include your name or any other identifying information. Your experience may be used anonymously for teaching purposes, but your name or other identifying information will not be shared.

Section 9. - VOLUNTARY NATURE OF PARTICIPATION

The use of ketamine in the context described herein has not been approved by the Food and Drug Administration (FDA). Under the federal Food, Drug and Cosmetic Act ketamine is approved for general use only as an anesthetic agent. This means that the FDA does not endorse the use of ketamine as a psychotherapeutic agent nor as a treatment for pain and classifies subanesthetic ketamine therapy as an investigational therapy nor does it endorse its use for inducing non-ordinary altered states of consciousness. These uses are considered off-label uses of ketamine.

Your decision to undertake ketamine non-ordinary altered-state experience is completely voluntary. Before you make your decision about participating in the ketamine non-ordinary altered-state experience, your Provider(s) will give you a chance to ask any questions and any concerns that you may have about the procedure.

Even after agreeing to undertake the ketamine non-ordinary altered-state experience, you may change your mind up until moment ketamine has been administered.

Section 10. - INFORMED CONSENT

Please read and check each of the statements below. By placing a checkmark beside each of them, you acknowledge that you understand all the information contained within them as well as the Agreement in its entirety and affirm that you give your consent to the administration of ketamine in the context of a guided non-ordinary altered-state of consciousness experience.

I have fully read the Agreement describing subanesthetic ketamine administration.

I understand and acknowledge ketamine is an approved medication by the FDA, but that the Company is using ketamine off-label.

I have had the opportunity to question one of the persons in charge of the ketamine non-ordinary altered-state experience and have received satisfactory answers.

I fully understand that ketamine sessions can result in profound changes in mental state and may (temporarily) result in unusual psychological and physiological effects.

I understand and acknowledge potential side effects include dizziness, nausea, vomiting, loss of appetite, euphoria, perceptual disturbances, bad dreams, confusion, changes in heartrate, changes in blood pressure, difficulty breathing, anxiety, itching, increased saliva production, musculoskeletal disruptions, rash, double vision, and unusual heart rhythms.

I understand and acknowledge possible complications include seizures, low blood pressure, high blood pressure, bleeding, infections, damage to nerves or surrounding tissues, failure to provide benefit, heart attack, stroke, and death.

I understand I am to have nothing in my stomach for 6 hours prior to the experience.

I understand that if I need to be somewhere else, it will be necessary to have someone drive me after the Experience and not engage in any driving or hazardous activity such as operating any type of machinery the day of the experience.

I understand and acknowledge I have been informed not to consume any alcohol, make any financial, business, or other decisions requiring my signature, or engage in activities requiring motor skills as ketamine may affect my mentation, memory, and motor skills. By doing any of these activities, I am going against medical advice and will be solely responsible for any accidents or problems that may arise by my actions.

I understand and acknowledge that I will call 911 for any life-threatening symptoms I may experience after the experience, including thoughts of suicide.

I understand and acknowledge that ketamine is not guaranteed or being promoted to provide any health benefit and I may not receive any benefit or may have worse symptoms even after multiple experiences.

I understand and acknowledge that ketamine sessions are part of my non-ordinary altered-state experience, and is not a replacement for my doctor’s plan nor any part thereof , and I will be compliant with my medical doctor's treatment plan for me. I will also update my other doctors on my experience results so any adjustments in traditional treatments may be altered or changed per their discretion.

I understand the risks and benefits, and I freely give my consent to participate in ketamine non-ordinary altered-state experience as outlined in the Agreement, under the conditions indicated in it.

I understand that I may withdraw my consent up until ketamine has been administered.

I understand and acknowledge that the Company and its principals and agents for the administration of this experience have the right to refuse to offer this experience to me at any time without cause.

I understand that I can request a copy of the Agreement at any time.

I have received the pre-experience and post-experience instructions.

I understand that the Company, the Provider(s), its agents and guides are not carrying malpractice insurance for any type of altered-state experience.

I understand that I have had the opportunity to raise questions and have received satisfactory answers.

I understand and accept the risks and benefits of the ketamine non-ordinary altered-state experience and I freely give my consent to participate in ketamine experiences as outlined in the Agreement and under the conditions indicated in it.

Section 11. INDEMNIFICATION

I understand and acknowledge that the Experience described within the Agreement regarding the use of ketamine may offer the possibility for changes in my physical or mental health. I understand and acknowledge that any such changes are not the intention nor focus of the non-ordinary altered-state experience described within the Agreement. I acknowledge and understand that the purpose of the private session and/or group workshop experience is to induce a temporary, non-ordinary altered state of consciousness by this off-label use of ketamine described herein.

Furthermore, by signing below I also acknowledge that I have carefully read the Agreement in its entirety and fully understand all terms contained within. In consideration of the risk of injury while participating in the ketamine non-ordinary altered-state experience, and as consideration for the right to participate in those experiences, I hereby, for myself, my heirs, executors, assigns, or personal representatives, knowingly and voluntarily enter into the Agreement and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in ketamine non-ordinary altered-state experiences and hereby release and forever discharge the "Company", their subsidiaries, affiliates, managers, members, agents, attorneys, staff, heirs, representatives, predecessors, successors and assigns (known collectively as “their Agents”) for any physical or psychological injury, including but not limited to illness, hospitalization, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in ketamine altered-state experiences, including traveling from the Company or their Agents. If litigation arises pursuant to any claim made by me or anyone else acting on my behalf, I agree to reimburse the Company and their Agents for any costs incurred, including attorney's fees, medical fees, and any related costs.

Furthermore, I shall defend, indemnify, and hold harmless the Company and their Agents against any and all losses, damages, liabilities, deficiencies, claims, actions, judgments, settlements, interest, awards, penalties, fines, costs, or expenses of whatever kind, including reasonable attorney fees, fees, the costs of enforcing any right to indemnification under the Agreement, and the cost of pursuing any insurance providers, awarded against the Company or their Agents arising out of or resulting from any claim of a third party related to my participation in the ketamine altered-state experience, including any claims arising out of my own negligence or the ordinary negligence of the Company or Their Agents.

Section 12. – ACKNOWLEDGEMENT AND SIGNATURE

By signing my name in the signature box below and typing my name in the box labeled "Full printed name", I electronically sign the Agreement and affirm it has the same effect as my handwritten signature under applicable law.

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A completed hardcopy of this agreement may be printed out for your records. Make sure to use your web browser's "print" function before clicking on the "submit" button below.

At your private session or the group workshop, you will also be asked to manually sign an affidavit on the day(s) of your experience(s) in the presence of witnesses to verify that you understand all the information and considerations presented in this agreement which includes the entire webpage contents (https://www.grokingwholeness.info/informed-consent-v3).