Facilitation Medical Consult Form
This form is specifically designed for Sacred Medicine Facilitators to streamline and enhance the client intake process. It serves as a structured guide to ensure that all relevant information is collected, enabling informed decision-making and personalized care. The questions included are meant to be asked directly to clients, facilitating an open and thorough exchange of essential details for the most effective and supportive consultation experience. Please allow 24–48 hours for processing after submission. Be sure to check your spam folder for an email from Kambo Kenaz.
Facilitator Name
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First Name
Last Name
Facilitator Contact Number
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Country Code
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Area Code
Phone Number
Facilitator Email Address
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Confirmation Email
example@example.com
Clients age?
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Clients' Sex at Birth?
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Please Select
Male
Female
N/A
Ask: Please provide me with the sex you were assigned at birth?
Client Activity Level: 1) How often do you exercise? 2) What types of exercise? 3) How long do you exercise for and how many times a week?
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MEDICAL & SURGICAL HISTORY 1) What is your medical history, and what year were you diagnosed? 2) What surgeries have you had in the past, for what reason, and in what year?
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Current ACTIVE Medical Conditions 1) What active medical conditions are you currently diagnosed with? 2) What is the severity of the condition? (If severity is unknown, this is okay)
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Are you currently taking any medication?
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Yes
No
PRESCRIPTION & OVER-THE-COUNTER MEDICATIONS: Must include WHY the medication is being taken, as some medicines are prescribed for off-label reasons. Example: Name, Dose, Frequency, Duration, and Indication.
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Regarding Prescription Medications: 1) Have you ever skipped a dose of any of these medications? - If yes, which medication? What happens when you don’t take the medication? What’s the longest you’ve gone without it?
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Do you use any kind of recreational substances or have you ever used them?
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Please Select
Yes
No
If yes, please share how often and how long you’ve been using them, and what types.
Do you consume alcohol? If Yes, how often?
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Daily
Weekly
Occasionally
Never
FOR THE FACILITATOR: Please state any specific questions, comments, or concerns that either you, the facilitator, or the client may have expressed to you
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NON-LIABILITY AGREEMENT FOR MEDICAL CONSULTING SERVICES
This Non-Liability Agreement (“Agreement”) is made and entered into as of the date signed below by and between Adrienne Perales (“Consultant”), and the Certified Kambo Practitioner and/or Client (“Practitioner” and/or “Client”), collectively referred to as the “Parties.” 1. Scope of Services The Consultant is providing medical consulting services for informational and educational purposes only. The Consultant is not acting as a licensed medical provider and is not diagnosing, treating, or prescribing for any medical conditions. The services provided do not constitute medical care, and no doctor-patient or nurse-client relationship is established. The Practitioner and/or Client acknowledge that all decisions regarding treatment or facilitation are solely their own responsibility. 2. Non-Liability of Consultant The Consultant shall not be held liable for any direct or indirect consequences, including but not limited to injury, illness, complications, or death arising from any medical decisions made by the Practitioner, Client, or any other party based on the Consultant’s advice or recommendations. The Practitioner and/or Client retain full responsibility for any actions, treatments, or protocols administered before, during, or after a Kambo session. The Consultant does not assume any responsibility for the outcome of such decisions or actions. 3. Separation from Medical Licensure The Consultant explicitly states that they are not providing services under any active medical license (e.g., RN, MD, NP, PA, etc.) and that their consulting is based solely on personal knowledge, experience, and research. The Practitioner and/or Client acknowledge and agree that this service is not regulated medical care and does not substitute professional diagnosis, treatment, or emergency intervention. The Practitioner further agrees to disclose to their Client that they are receiving consulting services from a Consultant who is not acting under a medical license. 4. No Warranties or Guarantees The Consultant expressly disclaims any warranties or guarantees, whether express or implied, regarding the accuracy, completeness, or effectiveness of the advice or recommendations provided during the consultation. The Consultant shall not be liable for any errors, omissions, or misinterpretations of information. 5. Consultant’s Limitation of Liability The Consultant’s liability under this Agreement shall be limited to the fees paid by the Practitioner for the specific consultation services rendered. In no event shall the Consultant be liable for any consequential, incidental, indirect, or punitive damages arising out of or related to the consultation services. 6. Indemnification Clause The Practitioner and/or Client agree to indemnify, defend, and hold harmless the Consultant from any and all claims, damages, liabilities, losses, costs, or expenses (including legal fees) arising from: Any actions taken based on the Consultant’s guidance. Any medical events, adverse reactions, or complications occurring during or after a Kambo session. Any claims related to the use, misinterpretation, or implementation of the Consultant’s recommendations. 7. No Establishment of Doctor-Patient or Nurse-Client Relationship The Parties acknowledge that the Consultant’s services do not establish a doctor-patient or nurse-client relationship with the Practitioner, Client, or any other individual. The Consultant shall not be considered a treating medical provider for the Practitioner, Client, or any other party. 8. Governing Law and Jurisdiction This Agreement shall be construed in accordance with the laws of the state/country where the Practitioner and Client reside. Any disputes arising from or related to this Agreement shall be subject to the exclusive jurisdiction of the courts in the Practitioner’s or Client’s jurisdiction. 9. Acknowledgment & Agreement By signing below, the Parties acknowledge that they have read, understand, and voluntarily agree to the terms outlined in this Agreement. The Practitioner and/or Client further acknowledge that they have been given the opportunity to seek legal counsel before signing this Agreement.
By clicking below, you confirm that you have READ AND AGREE to the Non-Liability Clause provided above.
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I have read and agree to Non-Liability Clause
By entering your full name below, you acknowledge and agree to the terms outlined in the Non-Liability Agreement.
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First Name
Last Name
Date
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Month
-
Day
Year
Date
Signature
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