Kambo Intake Form

Kambo Application
To ensure your safety in participating in a Kambo ceremony, please fill in the following intake form with radical honesty and great care. This applies to listing all medical conditions, medicines, supplements and any substances taken or being taken, as there may be contraindications that could pose a risk to your well-being and safety.

It is of the upmost importance that I understand where you are at when it comes to your current physical health and mental well-being to ensure that it is safe to administer Kambo to you at this time.

All your answers are kept confidential.
If there are details you consider too sensitive for this form, we can discuss the details in private on our consultation call.

Once you have finished this application form please go ahead and book in a 20 minute call with me using my >> calendar link.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

Name of next of kin

First NameLast Name

Phone Number

Please enter a valid phone number.

Their relationship to you?

Please describe any Physical Health Issues: (Past & Present)

Please Describe any Mental Health Issues: (Past & Present)

Have you ever been diagnosed with a mental health condition? Have you been prescribed psychiatric medications? If so which ones?

Please list what medication & supplements you are currently taking:

Are you or could you be pregnant?

Have you ever had heart surgery?

Have you had an organ transplant?

Do you drink alcohol? If so how much & how often?

Please describe if you have any phobias?

Do you have any allergies if so which ones?

Have you taken Bufo or Iboga in the last month? Please give exact dates & doses.

How many ties have you taken Kambo and when was the last time?

DISCLAIMER:

The [PROVIDER] does not provide liability insurance for the protection of individuals who may participate in a Kambo treatment.

In consideration for your participation in said Kambo treatment, the individual, does hereby release and forever discharge the [PROVIDER], and its officers, board, and employees, jointly and severally from any and all actions, causes of actions, claims and demands for, upon or by reason of any damage, loss or injury, which hereafter may be sustained by participating in a Kambo treatment.

This release extends and applies to, and also covers and includes, all unknown, unforeseen, unanticipated and unsuspected injuries, damages, loss and liability and the consequences thereof, as well as those now disclosed and known to exist. The provisions of any state, federal, local or territorial law or state providing substance that releases shall not extend to claims, demands, injuries, or damages which are known or unsuspected to exist at this time, to the person executing such release, are hereby expressly waived.

I hereby agree on behalf of my heirs, executors, administrators, and assigns, to indemnify the [PROVIDER] and its officers, board and employees, joint and severally from any and all actions, causes of actions, claims and demands for, upon or by reason of any damage, loss or injury, which hereafter may be sustained by participating in a kambo treatment.

It is further understood and agreed that said participation in the Kambo treatment is not to be construed as an admission of any liability and acceptance of assumption of responsibility by the [PROVIDER], its officers, board, and employees, jointly and severally, for all damages and expenses for which the [PROVIDER], its officers, board and employees, become liable as a result of any alleged act of the Kambo treatment participant.

All participants must complete this Liability Disclaimer to be eligible to participate in the Kambo Treatment

Signature