Name *

First Name

Last Name

Phone / WhatsApp *

Country

(###)

###

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By ticking the box you confirm that you are 18 years old or more *

I confirm that I am at least 18 years old

Do you want to attend a group ceremony or have private session *

Group ceremony

Private session

Both works for me

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. *

Please check the box to indicate that you have read and understood the above information.

What would you like to focus on - Mental Health

General Mental Health

Mental Abuse

Emotional Pain

Past Trauma

Release Negativity

What would you like to focus on - Physical Health

General Physical Health

Detox / Cleansing

Physical Pain

Migranes

Physical Abuse

Deep Trauma

Addiction

What would you like to focus on - Health and Well-Being

Life Purpose

Career Change

Creativity

Personal Growth

Learning

Curiosity

Heart Center

Medical History Information - Physical Health

Diabetes

Epilepsy or Seizures

Visual Impairment

Infectious Disease

Physical Disability

Thyroid Conditions

Ehlers-Danlos Syndrome

Addison’s Disease

Undergoing chemotherapy or radiation therapy

Medical History Information - Heart Health

High Blood Pressure

Low Blood Pressure

Circulatory Problems

Stroke

Heart Attack

Irregular Heartbeat

Aneurysms or Blood clots

Brain Haemorrhage

Medical History Information - Mental Health

Mental Disorder

Anxiety Disorder

Clinical Depression

Multiple Identity Disorder (MPD)

Bipolar

Schizophrenia

Suicidal Ideation

Self Harming

OCD

ADHD / ADD

PTSD

Autism

Alcoholism or Drug Addiction

Do you have any severe or potentially life-threatening allergies that would require the use of an epi pen? *

Yes

No

Are you currently pregnant? *

Yes

No

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. *

By clicking here, I agree with the above.

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. *

Check this box if you agree to our Health Screening and Full Disclosure.

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. *

Check this box if you agree to this Health Medications Note.

Have you attended a Kambo ceremony with us before?

Yes

No

Have you attended a Kambo ceremony with anyone else?

Yes

No

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. *

I accept the terms and conditions.

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. *

Check this box if you agree to our refund policy

Have you been vaccinated for Covid-19? *

Yes, more than 6 weeks ago

Yes, less than 6 weeks ago

No