Client Consent Waiver Form & Agreement

Kambo Waiver and Contraindications Agreement

Practitioner Information:

Name: Tara L. Meyer
Location: Dayton & Columbus Ohio

Purpose and Use of Kambo:

Kambo is a traditional Amazonian medicine that involves applying the secretion of the Phyllomedusa bicolor frog onto small burns on the skin. It is a non-psychoactive substance and is used by variouscultures in healing practices.

Contraindication Agreement:

Clients must not take kambo if any of the following apply.

◦ Serious heart problems
◦ Being on a no-salt diet (ayahuasca diet)
◦ Ehlers Danlos or Marfan syndrome
◦ Medication for low blood pressure
◦ History of stroke
◦ Current brain hemorrhage, or blood clots
◦ Lack the mental capacity to consent
◦ Serious mental health issues (excluding depression, PTSD, and anxiety)
◦ Undergoing chemotherapy, radiotherapy, or immunotherapy (6 weeks exclusion)
◦ Use of immune-suppressants for organ transplant
◦ Addison's Disease
◦ Current or severe epilepsy
◦ Recovering from major surgery
◦ Under 18 years old
◦ Pregnancy or breastfeeding
◦ Daily diuretic medication
◦ Consumption of other strong medicines within 24 hours (Ayahuasca, San Pedro, Mushrooms)
◦ Recent Covid Vaccine (4-week exclusion)
◦ Reached 70th birthday
◦ Fasting for longer than 18 hours

Substance Guideline List:

The following substances should be abstained from before and after a kambo session. Please confirm your agreement to each abstinence period by signing the end of this document.

◦ Alcohol (High Doses): 48 hours / 7 days
◦ Alcohol (Low Doses): 12 hours/ 24 hours
◦ Amphetamines (Adderall, Ritalin): 7 days/ 7 days
◦ Anti-Convulsants: Must discuss with facilitator
◦ Anti-Depressants & Anxiety: Do not take morning of treatment/ 2 hrs
◦ Anti-Epileptic: Contraindicated
◦ Anti-Psychotics: Contraindicated
◦ Ayahuasca & Analogues: 24 hours/ 24 hours
◦ Benzodiazepines (Valium, Diazepam): 18 hours/ 8 hours
◦ Beta Blockers: Do not take morning of treatment/ 8 hours
◦ Blood Thinners: Do not take the morning of treatment/ 8 hours
◦ Botox: 7 days/ 7 days
◦ Bufo, 5- meo dmt: 24 hours/ 6 weeks
◦ Cannabis: 12 hours/ 24 hours
◦ Cocaine: 3 days/ 5 days
◦ Crack Cocaine: 7 days/ 7 days
◦ DMT: 8 hours/ 8 hours
◦ MDMA & MDA (Ecstacy) 7 days/ 7 days
◦ Fentanyl: Contraindicated
◦ Heroin: 14 days/ 14 days
◦ Iboga: 90 days/ 24 hrs
◦ Ketamine 3 days/ 3 days
◦ LSD: 48 hours/ 72 hours
◦ Mescaline: 24 hours/ 24 hours
◦ Meth Amphetamine: 30 days/ 30 days
◦ Morphine/ Oxycodone: 5 days/ 5 days
◦ Psilocybin: 24 hrs/ 24 hrs
◦ Tramadol: 48 hours/ 24 hours
◦ Vasoconstrictors (Triptans): 3 days/ 12 hours
◦ COVID Vaccine 30 days/ 7 days

 

Liability Release and Assumption of Risk:

The kambo waiver and containdictations agreement absolves all responsibility for any potential injuries, both physical and psychological or death resulting from participation in a kambo session regardless of circumstances or disclosed health information.

The participant is of sound mind and acknowledges they are voluntarily engaging in this practice at their own risk.

An official license is not applicable since this is not an accredited profession and there are no governing bodies or regulations that exist for the sessions. However, Tara Meyer is proud to be a Tribal Detox trained and certified kambo application practitioner. She also has a certification in basic first aid, CPR, and the use of the AED thorugh the American Red Cross. Our focus, as practitioners, is to prioritize responsible kambo application and client safety.

Services:

Kambo sessions, practices and duration of effects can be varied with respect to the client’s obstacles, health, needs, wants and intentions. The practitioner may discontinue session with or without your consent at any time he/she feels it is in your best interest based upon his/her medical judgment regarding your safety or due to your willful failure to follow through.  

 

Rights:

The participant can withdraw from participation at any time and this will not affect the future practices and treatment.

 

Risks:

Kambo sessions have both benefits and risks for each person. Each participant may experience some desirable and undesirable feelings and sensations before, during and after each session. The client accepts the results are not certain and cannot be guaranteed.

 

Confidentiality:

Personal information, medical details, and other sensitive data provided in this waiver or during participation will be treated as confidential and are solely for the purpose of ensuring the safety, health, and well-being of the participant during the activity and will only be disclosed for necessary legal or medical reasons.

 

Emergency Medical Treatment: 

Reasonable efforts will be made to seek, obtain and provide any necessary medical treatment in the event of adverse reactions, emergency or injury along with contacting the emergency contact listed below.  

*You are consenting to the use of your electronic signature in lieu of a written signature. After consent, you have the right to request a paper copy for your records, upon written request.  Your agreement to use an electronic signature will continue until such time as you notify us that you would like to withdrawal your further consent.

You can print the form with "Print Form" before the submission in order to get a hard copy for your records.