MyShroom® Trial Signup

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

MyShroom is looking for patients with these illnesses:
Brain Cancer, Alzheimers, Type 1 Diabetes, Opioid Addiction, Kidney disease, misc. other diseases (please list below).
Qualifying patients will receive free product in return for supplying daily personal updates, medical history, and medical evaluation updates.

Email *

Please provide your full name *

Phone number where we can reach you during business hours *

Are you diagnosed with one of the following diseases? *

Brain Cancer

Alzheimer's Disease

Type 1 DIabetes

Opioid Addition due to pain management

Kidney Disease

Other:

May we share your trial updates anonymously with Indiegogo backers? *

A typical shared update might read: "David A with Opioid Addition reported reduced pain and a clearer mind after 7 days on the Immune Blend. Mary B with stage 4 Brain Cancer tells us that her tumor markers are 30% reduced per her last test."

Yes

Required

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of myshroom.com. Report Abuse

Forms