Application form for Kambo session If you wish to book a Kambo session, please fill out the application form below. All information are used strictly for deciding whether Kambo ceremony is suitable for you or not and will not be shared or exposed to anyone. Thank you! PERSONAL DATAILLNESSES AND MEDICATIONS1. Are you currently taking any medication and what dosage?YESNOMedication Dosage Reason 2. Do you have any chronic illness?YESNOPlease specify 3. Do you have any current medical conditions?YESNOPlease specify 4. Have you been vaccinated with covid vaccine?YESNOWith which one and how many times? 5. Do you have any allergies?YESNOPlease specify PHYSICAL AND MENTAL HEALTH6. Do you or have you in the past suffered from a psychological disorder?YESNOPlease specify 7. Have you experienced seizures or been diagnosed with epilepsy?YESNOPlease specify 8. Have you ever had a stroke, heart attack or any other heart related issues?YESNOPlease specify 9. Are you taking any drugs?YESNOPlease specify 10. Do you have a drug or alcohol addiction?YESNOPlease specify 11. Have you had an operation or surgery of any kind recently?YESNOPlease specify 12. Do you have any cardiovascular problems or very high/low blood pressure?YESNOPlease specify 13. Is there anything about your physical/mental state I should know about?YESNOPlease specify KAMBO14. Do you have previous experience working with Kambo medicine? YESNOIf so, please specify the last ones. 15. Why would you like to receive Kambo now? Please specify CONTRAIDICATIONKambo cannot safely be used if you have any of the following health conditions:If you have a heart conditionIf you have had a strokeIf you are on medication for blood pressureIf you have had a brain hemorrhageIf you have had an aneurysm or blood clotIf you have a serious mental health problemIf you are currently undergoing chemotherapy or for 6 weeks afterwardsIf you take immune-suppressant medication for an organ transplantIf you have had an organ transplanIf you have Addison’s DiseaseIf you have Esophageal varicesIf you are pregnantIf you are breastfeeding a child under 6 months of ageIf you have had any water-based detox within 3 days prior to your kambo treatment (for example: colonics, enemas, liver flushes)I hereby certify that I have accurately and truthfully completed the above Application Form and get acquainted with contraindications. I acknowledge that I am participating the session voluntarily and that I am solely and personally responsible for my choices, actions, and any results, now and in the future. I accept full responsibility for any consequences of Kambo use, or non-use. I’m happy to receive a newsletter on Katja’s current events and retreats when she’s travelling.
