Kambo Medical Intake Questionnaire

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Age

Gender

Email

example@example.com

Do you have any past or current health conditions?

Are you currently taking any medications, drugs or supplements? Name them below.

How many times have you received Kambo?

What are the reasons you are seeking out Kambo?

What and how many COVID-19 vaccines have you received and when?

Do you currently have or have had a heart condition or problem in the past?

Do you currently have or have had addison’s disease in the past?

Do you currently have or have had high blood pressure? and are you on medication for it?

Have you had a stroke, aneurysm, blood clot or bleeding in the brain?

Are you or may be pregnant?

Do you have have epilepsy or a history of seizures?

Do you have liver or kidney disease?

Do you have a history of schizophrenia, bipolar disorder, psychosis, mania or other serious psychiatric condition?

Have you have had an aneurysm, brain hemorrhage or other significant brain trauma?

Are you currently taking immunosuppressive drugs or steroids?

have you drank Ayahuasca in the last 3 weeks?

Have you taken Bufo or 5-meo-DMT in the last 4 weeks

have you experienced Ibogaine or Iboga within the last 3 weeks?

I verify that all of the information I have provided is accurate and known to be true to the best of my ability. I have not provided any false information that could potentially endanger myself, the practitioner or others participating in the ceremony. I agree to the above informed consent form and take full responsibility of my voluntary decision to experience Kambo

Signature

Informed Consent and Waiver to receive kambo from Pachamama Munai or affiliated practitioner.

This waiver states that you understand that participation in this kambo ceremony is likely to involve moderate to severe discomfort and has the potential for unexpected physical, mental or emotional upset. By signing this document you are waiving all rights to seek or receive compensation in case of injury, loss, or damage from any person or legal entity.

I acknowledge that my participation in this kambo ceremony is purely voluntary, and I agree to remain until the closing of the ceremony if I receive kambo.

During the ceremony, I will voluntarily receive a substance known as kambo. This substance is a natural secretion of the phyllomedusa bicolor, or giant monkey frog, native to the Amazon Basin in South America. I have been informed of its effects, and the reasons for taking it within the ceremony context and led by experienced kambo practitioners. I am called to participate in this ceremony as a result of my own research, hearing about other people’s experiences, and receiving information about its potential benefits including the possibility of ya profound spiritual experience. I understand that the facilitators will make no claim or promise regarding the curing of any illness or the nature of any spiritual experience. I understand that each ceremony experience is personal and sacred to every participant and that what may occur for one person, may not be experienced by others.

During the ceremony, I will voluntarily receive substances known as rapé, (a tobacco based snuff that is blown into the nostrils), and sananga (eye drops made from the roots of a tree native to the Amazon Basin in South America). I understand that both of these medicines can cause very intense and sometimes painful experiences when received, but will help to qualitatively improve my experience with kambo in this ceremony. I will make it clear to the facilitators if I currently am wearing contact lenses, or if there is any reason I should not partake in either of these two medicines.

I understand that this ceremony may be physically, mentally, emotionally, and/or spiritually demanding. I understand that I may experience dizziness, nausea, pain, swelling, cramping, and/or other physical upsets including vomiting and diarrhea. I accept full responsibility for anything that may occur during or following the ceremony, including emotional disturbance, mental disorientation and any and all possible manifestations of physical, emotional mental changes. I acknowledge that the risks and potential benefits of my participation have been explained to me and I freely choose to enter this process accepting full responsibility for whatever may occur, anticipated or unanticipated.

I understand that I may be physically or mentally exhausted and/or disoriented after the ceremony. I acknowledge that it is my responsibility to arrange alternate transportation, if needed at the conclusion of the ceremony.

I hereby acknowledge and voluntarily assume the full risks of any physical or mental injuries, damage or losses of any kind, either to myself or caused to others by me during this ceremony. I hereby waive the liability of and agree to hold harmless the facilitators, including all of its founders, members, associates, employees, agents, staff, family, successors, volunteers, and any and all property owners where the Ceremony occurs, and other participants. I further agree to defend and indemnify them from any claims, suits or demands. I understand that this agreement is binding upon me, my spouse, parents, family, heirs, executions, administrators, agents and assigns.

I agree that each and every provision of this agreement is independent of any other provision and may be enforced even if other provisions are not enforceable .

I HAVE READ AND UNDERSTAND THIS WAIVER, HAVE HAD TIME TO REFLECT UPON IT, AND SIGN THIS WAIVER VOLUNTARILY.

Name

First NameLast Name

Signature

Emergency Contact- Full name and phone number

Kambo Medical Intake Form