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Contact/General Information

Have you worked with Kambo before?
Yes
No
Have you worked with plant medicines before?
Yes
No

Health Information

Add Information provide here helps us to build on our knowledge and provide the safest practice possible. Thank you for taking the time to fill out this information honestly and completelyyour text

Please answer “YES” or “NO” for each of the following items to show that you have carefully read this list. If you answer “YES” please add details as needed. It’s crucial that you’re truthful in your answers- withholding any information can be harmful or even fatal.

Medications & Surgery

Have you stopped taking any medications in the last month?
Have you had surgery recently (include dental surgery)?

Heart Health

Were you born with any heart conditions?
Do you currently have any heart problems?
Have you had major heart surgery?
Can you tolerate aerobic exercise?

Neurological & Circulatory Health

Do you have epilepsy/seizure disorder?
Have you ever had a brain hemorrhage or stroke?
Have you ever had a blood clot?
Have you ever had an aneurism (weak blood vessels)?
Do you have abnormally high/low blood pressure?
Are you on medication for low blood pressure?
Do you have asthma?
Have you had an anaphylactic reaction to anything? If so, what?
Have you ever had any viral conditions (Lyme, herpes (cold sores), hepatitis, HPV, dengue)?
Are you on immune suppressants?
Are you undergoing chemotherapy or radiation, or have you recently?
Have you ever had any major surgeries?
Are you taking, or have recently stopped taking, diet/weight loss pills?
Are you taking, or have recently stopped taking, sleeping pills/supplements?
Are you taking medication that contains serotonin?
Have you taken a MAOI type drug or Bufo/5-MEO DMT in the last month?

Do you have a diagnosis of:

Diabetes (Type 1 or 2, using insulin?)
Addison's Disease
Reynaud's Disease
GERD, IBS or Crohn’s
Gastric ulcer or esophageal issues
History of bulimia or anorexia?
History of alcohol/drug addiction?
Is there any possibility you are pregnant?
Are you nursing a baby under 6 months old?
Are you undergoing fertility treatments?
Are you taking birth control pills?

Mental Health

Please let us know if you have ever had, or are currently dealing with, any mental health conditions, irrespective of whether you are taking medication. If you are on medication for mental health issues, it is crucial for your safety that you provide accurate information about your diagnosis, symptoms, and treatment plan. Thank you.

Do you have any history of psychosis?
Do you have any history of admittance to a mental health facility? If yes, why?
Have ever suspected you might be or have you been diagnosed on the Autism spectrum?
Have you been diagnosed with ADHD?
Have you been diagnosed with Borderline Personality Disorder?

Session/Retreat Agreement and Risk Waiver

I understand that our session(s) will include the use of traditional folk remedies used by indigenous people for good health. These remedies are collected and prepared in their natural environment; no regulations exist to guarantee their content, purity, or strength. I understand that these remedies are not approved or endorsed by the FDA and are being offered experimentally without implied safety or benefit.

Kambo is applied via superficial burns to the skin – these may permanently scar. Possible (rare) adverse reactions include – hyponatremia (low blood sodium that can lead to brain swelling), esophageal tears, conditions exacerbated by increased blood pressure, injury related to fainting, and others.

To the best of my knowledge, I am in good physical condition, and I am not aware of any physical or psychological infirmity that would place me at risk to participate in any way. I have answered the Health Intake Form honestly and been given the opportunity to have my questions answered.

I agree that I am always at choice on whether or not to participate, and I agree to take full responsibility for the choices I make involving this work, both during and after the event/session.

I agree to listen to and follow the instructions given by the facilitators.

Event facilitators reserve the right to ask anyone, at any time, to leave, with no refund, for any reason.

I understand this event/session is intended to be supportive and helpful in nature but is not a substitute for professional physical or mental health care. I am responsible for identifying if my situation also merits the services of a professional. I am responsible for seeking out further support if needed and release facilitators for any liability related to emotional or physical distress.

I agree to participate with the purest intention of heart, promoting the health and well-being of all participants. I will help create a safe and respectful space by holding the identity and experiences of anyone else in session as confidential.

Waiver Of Liability

I agree to release from all liability and waive my right to sue Kambolistica and its team from any claim, loss, liability, damage, or cost to persons or property arising from my attendance or participation in events/sessions, whether caused by the negligence of the released parties, or otherwise. I intend for this release and waiver to extend to my heirs and any other parties acting on my behalf.

Assumption Of The Risk

I assume full responsibility for any risk of bodily injury, illness, psychological damage, death, or property damage to myself, or others, arising from my attendance or participation in this event/session. In the event that any of the released parties are found liable to me, the total liability is limited to my admission fee.


My signature indicates I have read and understand the information provided in the above stated waiver and agree to be bound by this agreement. I sign voluntarily and with intent to execute this waiver for full and complete release of liability.

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