Wild Woman Kambo

Wild Woman Kambo

Health Form & Wavier
Participant Medical Information

The ceremony is primarily a spiritual undertaking and although personal growth often occurs, the experience should not be seen 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. If you have any doubt or concerns about whether you should participate, consult with the facilitator before attending. 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.
Please answer the following questions completely and honestly.

Your responses will remain strictly confidential.
Name

First NameLast Name
Email Address*
example@example.com
Contact Number*
Landline or Mobile Number
Age*
Emergency Contact

First NameLast Name
Emergency Contact Number
Do you have a history of, or currently live with of any of the following:

Cardiovascular Disease, including Heart AttacksHigh / Low Blood PressureMental Illness (Anxiety, Depression, Bipolar, Schizophrenia, etc.)Recent SurgeryPast or Recent Physical injuries (Fractures or Dislocations)Glaucoma, Retinal Detachment, Eye DisordersInfectious or Communicable DiseasesSeizures or EpilepsyAsthma or other Respiratory ConditionsDiabetesCancerDigestive IssuesChronic IllnessOrgan Donor/RecipientAddiction
Please provide further information for all health conditions selected.
List any pharmaceutical medications you are currently taking? Please include all medications, 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.
List any supplements, herbs or vitamins you have taken regularly over the past 2 months. Please include all supplements, dosage and frequency.
Please list any recreational or ceremonial substances you may have consumed in the last 6 months (including alcohol, tobacco, DMT, LSD, psilocybin, etc.). Please include the frequency of use.
Do you currently attend therapy or involved in any type of support group?
Are you pregnant, suspect you are pregnant or are breastfeeding?

YesNo
Is there anything else about your physical or mental health that we should be aware of?
Do you have experience working with Kambo or DMT? Please provide the approximate month/year of your last ceremony.
Please share your intention(s) for participating in ceremony. What are your intentions for receiving medicine? What are you hoping to gain or experience by working with the medicine? The more detail you provide, the better we can support you.
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 medicine 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.
Consent and Liability Waiver

I acknowledge that participation in the sacred ceremony may involve discomfort and unexpected physical, mental or emotional upset. 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.
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Wild Woman Kambo

Participant Medical Information

Please answer the following questions completely and honestly.

Your responses will remain strictly confidential.