Kambo Pre-Screen Questionnaire
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please list any current medications and/or supplements being taken, including the dosage and specifying why it is being taken. If none, type N/A.
*
Please list any medications and/or supplements taken in the last 6 months but are not currently using, and list the reason why it was being taken. If none, type N/A.
*
Have you ever used kambo in the past?
*
No
Yes
If yes to the answer above, please describe your experience(s) below.
Why are you interested in kambo?
Do you have any physical or medical conditions that I need to be aware of? If so, please list them below and if not type N/A.
*
Have you been hospitalized or had any surgical procedures (medical or dental) over the last 6 months? If so, please explain the reasoning and/or procedure with the date. Type N/A if there aren't any.
*
How would you describe your current mental and emotional state?
How did you find me? Please select one from the dropdown menu.
Please Select
Friend or Relative
Ebb and Float
Facebook
Instagram
Website
Word of mouth
Which kambo session(s) are you most interested in? Please select all that apply.
Microdose Single Dot Session (1 point)
Full Sapo Session
Sacred Trinity ( 3 sessions booked within a moon cycle)
Bring a Friend
Bring a Group
Which location would you prefer for your sessions? Please select one.
Dayton
Columbus (additional service charge)
House Call (additional service charge)
What days and time work best for your 20 minute Initiation Session phone call?
Is there anything else you may want to share with me now?
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
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