Love Kambo
help@lovekambo.com
www.lovekambo.com
Kambo Appointment Request Form
Fill the form below and we will get back soon to you for more updates and plan your appointment.
Name
First Name
Last Name
Age
Weight + Height
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact (Name + Phone Number)
Have you sat with Kambo before?
Yes
No
Have had serious heart conditions (those unable to do cardio)?
Yes
No
Are prescribed to medication for low blood pressure?
Yes
No
Have had a stroke or brain hemorrhage?
Yes
No
Have had an aneurysm or blood clots?
Yes
No
Have been diagnosed with mental illness other then anxiety, depression or PTSD?
Yes
No
Are currently undergoing chemotherapy or radiotherapy?
Yes
No
Are prescribed immunosuppressants?
Yes
No
Have Addison's disease?
Yes
No
Have current and severe epilepsy?
Yes
No
Are recovering from a major surgery?
Yes
No
Are under 18?
Yes
No
Are pregnant or breastfeeding a child under 6 months?
Yes
No
Are using melatonin or serotonin supplements.?
Yes
No
Have you ever had a manic episode?
Yes
No
Sat with Bufo within the last 2 weeks?
Yes
No
List any medications you are currently taking.
Have you been diagnosed with bipolar, borderline personality or schizophrenia?
Is there any specific physical pain lingering in your life?
Do you have any fears or phobias? If yes please specify.
Currently or in the past suffered from addiction, emotional, mental and/or psychological disorders (Assaults, Depression, Drug Addiction, Trauma)? If yes, please specify:
What sort of assistance and/or work have supported you to manage your conditions?
Do you use stimulants, recreational drugs or plant medicines, etc? (Type, Dosage and/or Frequency) *In working with Kambo, it's important to have full disclosure of substance use
Do you drink alcohol?
Yes
No
If yes, how frequently?
Do smoke marijuana?
Yes
No
If yes, how frequently?
Are you dealing with substance addiction/dependency? If yes, specify history and provide and current conditions:
List any surgeries or operations and their year: Examples include any time you've been under anesthesia, wisdom teeth removed, c-section, plastic surgery, cancer related, Transplant*, heart* etc: *Heart surgery and organ transplant are contradictions
Is there anything about your physical or mental state I need to be aware of? If yes, please specify:
Do you have any questions or concerns about the ceremony?
What do you hope to achieve by working with Kambo? *
How did you hear about Love Kambo?
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