Application form Kambo

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Application form Kambo
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Reiki Training Application
Sekhmet Reiki Training Application Form

Namn *

Först

Sist

Adress 1 (Street + Number) *

Adress 2 (Postal code + Town) *

Adress 3 (country if not Sweden)

E-post *

Date of Birth (YY/MM/DD) *

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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