Name
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First Name
Last Name
Email
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Phone / WhatsApp
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Country
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By ticking the box you confirm that you are 18 years old or more
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Do you want to attend a group ceremony or have private session
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IMPORTANT NOTE: If you have any health conditions or take any medications please email us at info@kambo.se to discuss your suitability for participating in a Kambo ceremony before you make a booking. Medications can not be taken in the morning of the day you take Kambo and some medications have to be stopped with doctor's permission up to one month before. Some health conditions make it very unsafe to participate in a Kambo ceremony.
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Birth Date
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MM
DD
YYYY
Gender
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Male
Female
What would you like to focus on - Mental Health
What would you like to focus on - Physical Health
What would you like to focus on - Health and Well-Being
Other areas you want to focus on
Medical History Information - Physical Health
Physical Health Details & Medications
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Please provide details if you check any condition. Include diagnosis history, any past and current medications including dosage and time on meds. Enter "none" if none of the above have been checked.
Recent injuries, surgeries or active disabilities
Medical History Information - Heart Health
Heart Health Details & Medications
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Please provide details if you check any condition. Include diagnosis history, any past and current medications including dosage and time on meds. Enter "none" if none of the above have been checked.
Medical History Information - Mental Health
Mental Health Details & Medications
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Please provide details if you check any condition. Include diagnosis history, any past and current medications including dosage and time on meds. Enter "none" if none of the above have been checked.
Please list any other medications you are currently taking including the dosage and time on medications.
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Enter "none" if you aren't currently taking any medications.
Please list any other medications you have taken in the past. Include when you took them and how long you were on them.
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Enter "none" if you haven't taken any medications in the past.
Please list any vitamins or supplements you are currently taking.
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Enter "none" if you aren't currently taking any vitamins or supplements.
Do you have any severe or potentially life-threatening allergies that would require the use of an epi pen?
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Please describe your allergies.
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If you have any allergies, please describe them in detail. If this does not apply to you, write "none".
Please list any recreational drugs you currently use.
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Enter "none" if you do not currently use any recreational drugs.
Please list any recreational drugs you have used in the past.
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Enter "none" if you have not used any recreational drugs in the past.
Are you currently pregnant?
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Pregnancy Disclaimer: I understand that Kambo is a purgative and can cause a miscarriage. I understand that Kambo is not recommended while breast feeding a child under the age of six months. If I become pregnant before the session, I understand that I am responsible for notifying my Kambo practitioner and that I will not be able to participate in a Kambo ceremony.
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Health Screening & Full Disclosure: We carefully screen each client for their safety prior to attending a Kambo ceremony. All herbal supplements, natural medicines, and medications (prescription and over-the-counter) must be disclosed and subsequently approved for use by us. All herbal supplements, natural medicines, and medications (prescription and over-the-counter) cannot be taken in the morning of the day you attend the ceremony, with the exception of birth control pills. You hereby agree that all information you provide in the application is correct and current and that you have disclosed all physical and psychological conditions as well as all herbal supplements, natural medicines and medications (prescription and over-the-counter) that you are taking. In some cases, you will be contacted personally by one of our staff to ensure that you are prepared for the experience. Our practitioners are not licensed medical doctors, psychologists, or psychiatrists. We do not practice medicine, diagnose, cure, or treat disease or illnesses. Instead, we function as spiritual guides and teachers and offer ceremony for the purpose of spiritual communion and growth. Dietary Restrictions: The day before Kambo we recommend you to restrain from all kind of refined sugar, red meat, non organic and processed foods. You will be advised of all restrictions a few days before your Kambo ceremony. Each specific set of restrictions should be followed. Consumption of alcohol is not allowed 48 hours before you arrive, the time of restriction for street drugs can vary from 48 hours to 6 weeks and some drugs are contraindicated.
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Medications Note: For your safety our practitioners have a "no medications / vitamins / supplements policy" the morning of a Kambo ceremony (this does not include birth control pills). Medical studies have shown that mixing medications and some supplements with Kambo can be dangerous and potentially fatal. Our representatives are not licensed to give advice on prescription medications. If you are currently taking medications, please consult with your doctor before discontinuing any medications.
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Have you attended a Kambo ceremony with us before?
Have you attended a Kambo ceremony with anyone else?
With whom?
Please read and agree to the terms indicated here: By checking the box and typing my name in the field below, I attest that I have read and understand all of the above written medical information and have openly disclosed all requested health and medical facts. I attest that the information provided above is true and complete, to the best of my knowledge. I understand that falsifying or omitting any relevant information may be grounds for denying my attendance at the ceremony for which I am applying, with or without a refund, at the sole discretion of Kambo.se, I hereby waive, release and hold harmless Kambo.se and it's practitioners from any and all liability or responsibility for all injuries and/or damages or claims which may occur in the event I do attend the ceremony.
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I understand that if I don't show up for the ceremony or cancel my booking within 24h before the ceremony starts, I will not be refunded my deposit. You will be asked to pay the deposit when this questionnaire has been approved and your booking is confirmed.
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Have you been vaccinated for Covid-19?
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Please type your name in CAPITAL letters:
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