Christmas POP-UP Shop - Vendor Registration

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INSTRUCTIONS

The ceremony is primarily a spiritual undertaking and although personal growth can occur, the experience, it should not be seen, nor is it designed as a substitute for psychotherapy.

Participation in the ceremony can involve dramatic experiences accompanied by strong emotional and physical release.
This ceremony is not appropriate for persons with certain medical conditions or for persons using certain medications.

Taking the time to complete this help me to determine your eligibility, address any of your questions, and ultimately better guide you through your process.

If you have any doubt or concerns about whether you should participate, please request a phone consultation.

jordanaricketts@gmail.com

416-931-6957

Participants must answer the following questions honestly in order for us to evaluate your ability to attend the event. Failure to disclose any medical condition or medication can result in hazardous conditions for the participant and you assume full liability for yourself in this instance.
The organizers accept no liability for any conditions arising from false or incomplete information provided by
event applicants.
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Please answer the following questions as completely and honestly as possible. Your responses will remain strictly confidential.
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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
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Gender* This field is required.
Female
Male
Other
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Age* This field is required.
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Emergency Contact* This field is required.
First and Last Name
Relationship
Phone Number
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Current Physician* This field is required.
First and Last Name
Phone Number
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Do you have a past history of, or currently suffer from any of the following? If yes please elaborate.* This field is required.
YES
NO
Cardiovascular disease, including heart attacks
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High / low Blood Pressure.
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Diagnosed Mental illness
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Row 2, Column 1
Recent surgery
Row 3, Column 0
Row 3, Column 1
Past or recent physical injuries (fractures or dislocations)
Row 4, Column 0
Row 4, Column 1
Glaucoma
Row 5, Column 0
Row 5, Column 1
Retinal detachment
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Row 6, Column 1
Infectious or communicable diseases.
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Epilepsy
Row 8, Column 0
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Asthma
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Diabetes
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Schizophrenia
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Bipolar
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Depression or anxiety
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Recent Surgeries
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Row 14, Column 1
Organ donor/recipient
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Row 15, Column 1
Cardiovascular disease, including heart attacks
High / low Blood Pressure.
Diagnosed Mental illness
Recent surgery
Past or recent physical injuries (fractures or dislocations)
Glaucoma
Retinal detachment
Infectious or communicable diseases.
Epilepsy
Asthma
Diabetes
Schizophrenia
Bipolar
Depression or anxiety
Recent Surgeries
Organ donor/recipient
YES
Row 0, Column 0
NO
Row 0, Column 1
YES
Row 1, Column 0
NO
Row 1, Column 1
YES
Row 2, Column 0
NO
Row 2, Column 1
YES
Row 3, Column 0
NO
Row 3, Column 1
YES
Row 4, Column 0
NO
Row 4, Column 1
YES
Row 5, Column 0
NO
Row 5, Column 1
YES
Row 6, Column 0
NO
Row 6, Column 1
YES
Row 7, Column 0
NO
Row 7, Column 1
YES
Row 8, Column 0
NO
Row 8, Column 1
YES
Row 9, Column 0
NO
Row 9, Column 1
YES
Row 10, Column 0
NO
Row 10, Column 1
YES
Row 11, Column 0
NO
Row 11, Column 1
YES
Row 12, Column 0
NO
Row 12, Column 1
YES
Row 13, Column 0
NO
Row 13, Column 1
YES
Row 14, Column 0
NO
Row 14, Column 1
YES
Row 15, Column 0
NO
Row 15, Column 1
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Have you done Kambo before?
YESNO
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Are you possibly pregnant, trying or breastfeeding?
YES - let's discuss
NO
POSSIBLY
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Have you been hospitalized for medical reasons in the past 5 years? (If yes please elaborate.)* This field is required.
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Ok
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Have you ever been hospitalized for psychiatric reasons? (If yes please elaborate.)* This field is required.
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Ok
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Are you currently in therapy or involved in any type of support group? (If yes please elaborate)* This field is required.
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Please list any medications and recreational drugs that you are currently taking, or have taken in the past 12 months.(Prescribed or over the counter) Please include dosage and frequency taken.** ABSOLUTE DISCRETION WILL BE HONOURED* This field is required.**Please note that it is imperative that you provide an accurate and detailed list of medications, as the plant medicine can dramatically increase the effects of certain medications to the point of becoming dangerous.**
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List any supplements (herbs or vitamins) that you have taken regularly in the past 2 months.**.* This field is required.**Please note that it is imperative that you provide an accurate and detailed list of medications, as Kambo can dramatically increase the effects of certain medications to the point of becoming dangerous**
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Do you have any heart or blood pressure irregularities?YES IT WAS ASKED ABOVE, BUT IT IS AN IMPORTANT FACTOR IN TREATMENT
YES - let's discuss
NO
POSSIBLY - let's discuss
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Have you ever had any type of seizure?
YESNO
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Are you currently taking any medication for any psychiatric disorder, SSRI medication for depression or other issue?* This field is required.Examples: Prozac, Seroxat, Zoloft, Effexor, Paxil, Welbutrin (bupropion), Zyban ,Pristiq, Cymbalta, Ixel, Effexor, Tramadol, Tramal, Ultram, Sibutramine, Meridia, Reductil, Axiomin, Etonin, Lubazodone, Serzone, Nefadar, Trazodone, Desyrel, Strattera, Edronax, Vivalan, Focalin, Ritalin, Concerta, Adderall, Dexedrine, Desoxyn, Vyvanse, Elavil, Endep, Evadene, Clomipramine, Anafranil, Desipramine (Norpramin, Pertofrane), Amoxapine (Asendin), Maprotiline (Ludiomil), Mianserin (Bolvidon, Norval, Tolvon), Mirtazapine (Remeron), Isocarboxazid (Marplan), Moclobemide, Aurorix, Manerix), Phenelzine (Nardil), Pirlindole (Pirazidol), Selegiline , Eldepryl, Zelapar, Emsam, Tranylcypromine (Parnate), Lithium, or other
YESNO
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If yes- what medication, when, for how long? What was the dosage? What was the reason for medication?
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Do you have allergies.* This field is required.
YESNO
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Are you taking medication to quit smoking (Wellbutrin (bupropion), Zyban)?* This field is required.
YESNO
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Is there anything else about your physical or mental health that we should be aware of?
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What are your intentions for receiving sacred medicine? What are you hoping to gain or experience by working with this medicine?
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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, heroin, and crack. If you have been using any drugs, medical, over the counter, or street, please advise Marko prior to attending any Kambo Ceremony to discuss this matter further.

For individuals who have received the COVID vaccine, it is recommended that you wait 4-6 weeks as a precaution.
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Please note that ceremonies should not be seen as, nor are they designed to be, a substitute for psychiatric or medical care. I hereby 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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Once we have received your completed application we will follow up with a phone call if there is anything that we need to discuss. If not, we will send you a link for payment.
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