Kambo Intake form
PERSONAL INFORMATION
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Facebook
This is for Human Verification
Twitter
This is for Human Verification
Instagram
This is for Human Verification
Emergency Contact Name
*
First Name
Last Name
Relationship
*
Emergency Contact Phone
*
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.
EXPERIENCE AND HEALTH INFORMATION
Do you have previous experience with Kambo?
Yes
No
Dates & Conditions Treated
Practitioner Information
Please elaborate
Do you have previous experience with any other shamanic medicines?
Yes
No
Please Specify
Do you have any known allergies (e.g., nuts, shellfish, other foods, insect stings, plants/herbs, medications)?
Yes
No
Please Specify
Do any of the above allergies require administration of an EpiPen?
Yes
No
Are you currently taking any prescribed medications?
Yes
No
Please specify and list medications
Are you currently taking any over-the-counter medications or supplements?
Yes
No
Please specify and list them
Are you currently receiving professional treatment for any medical or psychological condition(s)?
Yes
No
Do you have any known medical conditions or chronic illnesses?
Yes
No
Please Specify
Do you, or have you ever, suffered from psychological or psychiatric illness?
Yes
No
Please Specify
Have you had surgery or an operation of any kind recently?
Yes
No
Please Specify
Do you have any history of cardiovascular problems?
Yes
No
If yes, please specify
Have you ever experienced seizures or been diagnosed with epilepsy?
Yes
No
If yes, are you on medication?
Yes
No
Please Specify
Do you use recreational drugs or stimulants of any kind?
Yes
No
Please specify and list them
Do you drink alcohol (regularly or otherwise)?
Yes
No
Do you have any history of addiction (drug, alcohol, behavioral, etc.)?
Yes
No
Please Specify
Do you consider yourself a current addict or dependent on substances?
Yes
No
Please Specify
Have you tried in the past to quit but been unsuccessful?
Yes
No
Please Specify
Do you agree to discontinue use of recreational drugs and alcohol for at least 72 hours before the ceremony?
Yes
No
Are you currently aware of any energy blockages that may surface during the course of the ceremony?
Yes
No
Please Specify:
If you answered "Yes" to any of the above questions, have you dealt with these issues previously?
Yes
No
Were you successful?
Yes
No
Please Specify
If you answered "Yes" to any of the above questions, is there anything specific the facilitator(s) should know to help facilitate this energy purge more readily?
Yes
No
Please Specify
Is there anything about your physical, mental, emotional, or spiritual state that the facilitator(s) should know?
Yes
No
Please Specify
Is there anything else you feel led to share?
INDEMNITY AND RELEASE OF LIABILITY
I understand and agree that participation in the Kambo ceremony involves certain risks and that I am voluntarily assuming all such risks. I release and hold harmless the facilitators, organizers, and all associated parties from any liability, claims, or damages arising from my participation. I consent to the use of my information for the purposes of this ceremony and acknowledge that the facilitators are not medical professionals and do not provide medical advice or treatment. I have disclosed all relevant medical history and understand the importance of doing so for my safety and the safety of others.
*
Signature for Confirmation
*
Submit
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