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Namn
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Adress 1 (Street + Number)
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Adress 2 (Postal code + Town)
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Adress 3 (country if not Sweden)
E-post
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Date of Birth (YY/MM/DD)
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Phone Number
Is it your first time taking Kambo?
*
yes
no
If your last answer is no, please describe your history with Kambo shortly.
*
Do you have any other experiences with sacred medicines?
yes
no
If your last answer is yes, please share your experiences shortly.
Do you have any heart problems?
*
yes
no
Have you ever had heart issues, blood pressure issues, blood clots or epilepsy?
*
Have you ever had any blood borne disease such as Hepatitis or HIV etc?
*
Have you ever been diagnosed with a serious psychiatric illness? (EXCLUDING PTSD, anxiety/despression)
*
Have you ever had an organ transplant?
*
Have you ever experienced chest pains, dizziness or fanting?
*
Have you planed any major operations 1 month post or prior to the Session?
*
yes
no
Are you on any medications? If YES, please state which ones and for how long.
*
Do or did you have any problems with Anorexia or Obesity?
*
yes
no
Are there any other medical issues that you want me to be aware of? (all information given is confidential)
*
I confirm that I am over 18 years old
*
yes
no
I give my full consent for the application of Kambo. I understand that this will involve superficial burning of the skin.
*
yes
no
I understand that no claims has been made that Kambo can treat or cure any disease or illness.
*
yes
no
I understand that Kambo is not a substitute for medical treatment.
*
yes
no
I declare that the information I left above is correct and complete to my best knowledge. I also understand that participation in the sessions is on my own risk.
*
yes
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