Kambo Waiver

To ensure your safety and well-being during the Kambo ceremony, I kindly ask that you complete a waiver beforehand. This form helps me understand your medical history and any potential concerns, allowing me to provide the best possible care and support throughout your experience. It is crucial that you provide this information honestly and in its entirety. Your cooperation in filling out the waiver is greatly appreciated and will help create a safe and nurturing environment for your transformative journey.

KAMBO WAIVER

Please fill out the following form.

First name

Last name

Date of birth

Contact in case of emergency?

How did you hear about me?

Have you experienced Kambo before?

Kambo is a profound healing medicine that works deeply, requiring careful respect to customize your experience according to your unique needs. Your privacy is of utmost importance, and all information shared with me remains strictly confidential and any behaviours or recreational drug use will not be judged but rather taken into consideration. Before proceeding, I kindly request a thorough overview of your health and well-being.

Please note that Kambo is entirely safe when administered by a properly trained practitioner. I am proud to be fully Certified Kambo Practitioner under the International Association of Kambo Practitioners (IAKP). For more details about this organization, you can visit www.IAKP.org.

If you are menstruating during your session, please note that Kambo may temporarily increase flow for 24-36 hours due to its potent vasodilators. For those with asthma, it's important to have your inhaler on hand. If you have diabetes or have recently engaged in prolonged water fasting, please discuss your situation with us beforehand.

Do you currently have any medical conditions?

yes

have some symptoms that bother me

If you answered 'yes' to the previous question, are you currently in the care of a health care professional?

yes

Do you have a history or present condition of high or low blood pressure?

yes

Describe any surgeries, major accidents, and hospitalisations:

Date of last menstrual period:

Conditions of the Oesophagus:

Because Kambo can cause violent vomiting we need to have some caution around certain conditions that could weaken the Oesophagus/Esophagus. These do not necessarily preclude you from experiencing Kambo but it is advisable to make sure to let know if you have been affected with any of the following:

Conditions of the Oesophagus:

Boerhaave’s Syndrome (spontaneous rupture of the oesophagus)

Severe injury, or trauma to the Oesophagus/Esophagus from endoscopy, or injury to the neck

Tumours, or Ulcers in the throat

Those who have or have had bulimia

Gastro-intestinal Reflux

Chronic inflammatory response syndrome due to mold exposure

Untreated eosinophilic esophagitis

Oesophagus/Esophagus Varices

Portal Hypertension

Please describe any conditions you checked. Please indicate whether they are past or present.

Do you currently have any health challenges?

Have you had any health challenges in the past?

Do you use any recreational drugs?

Have you used any entheogens, psychedelics or other substances the in last 3 months?

Supplements

Please provide any other information you think might be relevant:

Psychological Health

To ensure your safety and well-being during your ceremony it's important that I am fully aware of any psychological health conditions you are currently experiencing or have had in the past. Please answer the following questions as honestly as possible. Rest assured, your information will remain confidential and will only be used to provide you with the best possible care.

Have you had or do you currently have any mental health challenges?

Please provide any other information you think might be relevant or important for me to know:

Disclaimer

I will disclose all prescribed medications, medical treatments, or therapy I am taking or undergoing.

I have read, understand and will comply with the medical guidelines and our safety policies.

I have read and understood the information in this medical form.

I have answered all the above questions fully and honestly and have not withheld any information that could be important.

I will discontinue all use of recreational, street drugs and non-prescribed pharmaceuticals at least three weeks before commencing with Kambo. Many street and recreational drugs are strongly contraindicated and can be dangerous and potentially fatal.

Date

Full name

Signature

Thank you!

Thank you so much for taking the time to complete this part of the intake. Your information is invaluable in helping me work safely with you and ensuring I can offer you the best possible support. I truly appreciate your cooperation and look forward to sharing this journey with you.

Mahalo, Nikka Alma