Kambo Tribe DUBAI

Warrior Intake and Medical History Form

Please only fill out this form once you have already made the decision to take Kambo. Answer as honestly and accurately as possible, this is a confidential & judgment-free zone.
Name and Surname*

NameSurname
E-mail*
Gender
Date of birth

MonthDayYear
Height
Weight
Contact telephone *
Address:

Street and number

CityProvince

Postal code
In case of emergency
Contact:*

NameSurname
Relationship:*
Contact Telephone:*
Are you currently taking any medication or vitamins?:*

YesNo
If the answer is yes, please write which ones, what for, and how often

Although Kambo is completely safe when administered correctly, there are some situations where Kambo is contraindicated and cautioned against. These conditions are listed below

* Serious heart problems or those who have had heart surgery. (This includes a Pacemaker but excludes Stents)

* Stroke or a brain haemorrhage

* Have an aneurism or blood clot

*Are recovering from a major surgical procedure with internal stitches

*Are on medication for low blood pressure

*Lack the mental capacity to make the decision to take Kambo

*Serious mental health problems, (excluding depression, PTSD and anxiety)

*Are undergoing chemotherapy, radiotherapy or have done so within the last 4 weeks

*Are taking immune-suppressants after organ transplant

*Addison’s Disease

*Current and severe epilepsy

*Recovering from a major surgical procedure

*Under 18 years old

*Certain types of Ehlers-Dalos Syndrome (EDS)

*Currently Pregnant or breast-feeding a child under 6 months old

*Have consumed Bufo, Iboga 90 or Ibogaine in the last 6 weeks

*Fasting, juice cleanses, steam room, sauna, hot yoga and hydrocolon therapy 3 days before or after your Kambo treatment
I have read the above contraindications and I confirm that I am completely compatible to take Kambo*

Yes, I am compatible to take KamboNo

Warrior Intake and Medical History Form