Confidential Kambo Intake And Consent Form

Full (Legal) Name

First NameLast Name

Preferred Name and Pronouns (if applicable)

Email

example@example.com

Phone Number

Please enter a valid phone number.

To attend a Kambo Ceremony, you must be 18 years of age or older to consent. Are you 18 years of age or older?

Yes, I am 18 years of age or olderNo, I am under 18 years of age

Please state your age

What is your date of birth?

Date

What is your Sun, Moon and Rising sign? (optional)

How did you hear about Meadow Healing Arts?

Is this your first time receiving Kambo?

What brings you to Kambo now and/or what brought you to Kambo in the past?

Do you have experience with other plant, fungi, or animal medicines?

Please list any allergies below.

Are you taking any medications or supplements?

YesNo

If yes, Please list all medications and supplements below.

Have you ever suffered from a stroke, anuerysm, blood clots, heart disease or any sort of heart related condition?

YesNo

If yes, please explain in detail any or all that may apply

Please state any other medical conditions I should be aware of that may have not been listed above.

Do you have a history of fainting, dizziness, or chest pains? If so please state clearly below.

Have you ever been diagnosed with ANY psychiatric illness?

YesNo

If yes, please write any and all diagnosis

Do you have any physical disabilities? If so, please state clearly so we can best assist you.

Do you have any addictions or dependencies to any drugs or alcohol?

YesNo

If yes, please give any details here.

Have you experienced any other entheogenic medicines in the last 14 days?

YesNo

If yes, please give any details here.

I CONFIRM I am not pregnant or breastfeeding.

I Confirm

I CONFIRM I will be fasted 8-12 hours before my Kambo session.

I Confirm

I CONFIRM I will be intoxicant and medication free for my session.

I Confirm

I understand that there will be some self-care recommendations for after working with Kambo that I am advised to follow.

I understand

Please select which of the following options you are booking.

Kambo - Single sessionKambo - 2 sessionsKambo - 3 sessions (trinity)

Address (for newsletters or a home visit)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.

I CONFIRM that all of my answers have been honest, for my safety and the safety of others.

I Confirm

I fully understand that it is my responsibility to inform Megan Kelly of any medical conditions or addictions I have that may affect my ability to attend a Kambo session and to update this information as necessary. I will not hold Megan Kelly liable in any way for any injuries that may occur during a Kambo session

I agreeI do not agree

Please sign to confirm above statement

Ceremony Preparation Guide

Fasting is mandatory 8-12 hours prior to your ceremony whether it is in the morning or at night.

No caffeine the day of your Kambo ceremony. (caffeine can be consumed after)

No medications taken the day of your Kambo ceremony. (details will be discussed over the phone depeding on the medication and client situation)

No drugs or Alcohol prior to ceremony (Time frames vary depending on the drug and alcohol content)

No DMT (NN & 5MEO) or MDMA two weeks prior to ceremony.

Eat organic, whole foods in the days leading up.

Avoid sugar at LEAST 3 days prior.

Minimize screen time and unhealthy interactions as best you can!

And please remeber Kambo is a graceful and forgiving medicine, just do your best, no need to be rigid with yourself in the process.

And most importantly.......Connect with the spirit Kambo!

Thank You!

If you have any further questions please email or call. Further prep information will be discussed further via phone call based on the above information provided. I look forward to working with you!

Megan @Meadow Healing Arts

megan@meadowhealingarts.com