Wild Woman Kambo

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Please answer the following questions as completely and honestly.

Your responses will remain strictly confidential.
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Name
First Name
Last Name
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Email Address* This field is required.
example@example.com
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Contact Number* This field is required.
Landline or Mobile Number
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Age* This field is required.
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Emergency Contact
First Name
Last Name
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Emergency Contact Number
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Do you have a history of, or currently live with of any of the following:
Cardiovascular Disease, including Heart Attacks
High / Low Blood Pressure
Mental Illness (Anxiety, Depression, Bipolar, Schizophrenia, etc.)
Recent Surgery
Past or Recent Physical injuries (Fractures or Dislocations)
Glaucoma, Retinal Detachment, Eye Disorders
Infectious or Communicable Diseases
Seizures or Epilepsy
Asthma or other Respiratory Conditions
Diabetes
Cancer
Digestive Issues
Chronic Illness
Organ Donor/Recipient
Addiction
Other
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Please provide further information for all health conditions selected - Diagnosis, severity etc.
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List any pharmaceutical medications you are currently taking? Please include all medications (in detail), dosage and frequency.
PLEASE NOTE: it is imperative that you provide an accurate & detailed list of medications, as Kambo can dramatically increase the effects of certain medications to the point of becoming dangerous.
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List any supplements, herbs or vitamins you have taken regularly over the past 2 months. Please include all supplements, dosage and frequency.
PLEASE NOTE: that it is imperative that you provide a complete list of any supplements taken regularly, as Kambo can dramatically increase the effects of certain supplements to the point of becoming dangerous.
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Please list any recreational or ceremonial substances you may have consumed in the last 6 months (including alcohol, tobacco, marijuana, LSD, psilocybin, etc.). Please include the frequency of use.
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Do you currently attend therapy or involved in any type of support group?
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Are you pregnant, suspect you are pregnant or are breastfeeding?
Yes
No
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Have you received an mRNA vaccine? If yes, please provide the following information below: Date of Vaccine(s) and list any side effects experienced.
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Is there anything else about your physical or mental health that we should be aware of?
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Have you have experience working with Kambo? Please provide the approximate month/year of your last ceremony and name of your practitioner(s)
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What are your intentions for receiving Kambo? What are you hoping to gain or experience by working with the medicine? Please share your intention(s) for participating. The more detail you provide, the better we can support you.
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Please be aware that the list of contraindicated substances includes, but is not limited to, SSRIs, Demerol, cold medication, decongestants, sinus medication, nasal sprays, hay fever medications, diet pills, amphetamines, MDMA or ecstasy, cocaine, heroine, and crack. If you have been using any drugs, medical, over the counter, or street, please advise the facilitators prior to recieving kambo to discuss this matter further.

Please note that ceremonies should not be seen as, nor are they designed to be, a substitute for psychiatric or medical care.

I confirm that I have read and understood the above information and have answered all the questions completely and honestly and have not withheld any information.
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Consent and Liability Waiver

I acknowledge that participation in the sacred ceremony may involve discomfort and unexpected physical, mental or emotional upset. In submitting this release document, I agree to waive all rights to seek or receive compensation in case of injury, loss or damage.

I choose to attend this work as a result of my research and interest in ceremonies. I understand that my participation in this ceremony is entirely voluntary and I agree to remain at the ceremony to its completion. I accept that the ceremony practitioners make no claim or promise about the curing of illness of any kind, or about the nature of any spiritual experience which I understand is entirely personal.

I understand that my participation in the ceremony may be physically, mentally, emotionally or spiritually demanding. I understand that I may experience dizziness, nausea or other physical upset including vomiting and diarrhea. I accept full responsibility for anything that may occur including emotional disturbance, mental disorientation and any and all possible manifestations of physical, emotional and mental changes. I acknowledge that I am aware of the risks and potential benefits of my participation and I freely choose to enter this process, accepting full responsibility for whatever may occur whether anticipated or unanticipated.

I am informed of the nature of the ceremony, the needed preparation and the rules of the ceremonies. I commit myself to stay in the circle until the end of the ceremony and to respect the directives given by the organizers, helpers and facilitators(s) of the ceremony.

I hereby knowingly and voluntarily assume the full risks of any physical or moral injury, damage or losses, either to myself or caused to others by me during the Ceremony.

I hereby waive the liability of and agree to hold harmless:

the practitioner(s), all the helpers, associates, employees, agents, staff, family successors, volunteers and other participants. I further agree to defend and indemnify them from any claims, suits and demands. This agreement is binding upon myself, my spouse, parents, family, heirs, executors, administrators, agents and assigns.
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Media ConsentDo you grant access to photos/videos that may or may not include your face or body part showcasing the medicine in the context of education.
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*Pre-ceremony Preparation Call*Please provide your availabilities to tune for a 45min call to connect, prepare and provide more information for what the ceremony will entail.
example@example.com
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If you are ready to book your ceremony, please pick a date that best works for you, between 11 AM to 2PM
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*Please Note*

Once you've confirmed your ceremony date, to secure your spot you must etransfer $100 to maureenbornilla@gmail.com

Deposit is trasnfferable however nonrefundable.
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Signature* This field is required.
Clear
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Sapo Ceremony Preparation PDF
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Please answer the following questions as completely and honestly.

Your responses will remain strictly confidential.