Kambo VIP Intake form

Medical Information & Waiver

Please fill out this medical information form honestly and to its entirety. Your safety is our first priority and in order to determine whether our offerings are safe for you, we require full disclosure.

Full Legal Name*

This field is mandatory

E-mail*

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The e-mail address is invalid

Physical Address*

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Phone Number*

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Emergency Contact Name*

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Emergency Contact Telephone number*

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Any Cardiovascular Issues? IE: Blood Presure, Heart problems, Circulation (blood clotting, vericose veins), Numbing of hands, arms, feet or legs? If yes, please explain*

This field is mandatory

Any mental health issues or diagnoses? IE: depression, anxiety, psychosis, schizophrenia, Borderline Personality Disorder, Narcissistic Personality Disorder, Aspergers, Autism? If Yes, please explain*

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Any health issues? IE: Epilepsy, Transplant recipient/donor, recent surgeries, glaucoma, skin conditions, sleep disorders, kidney issues, physical injuries, diabetes. If yes, please explain*

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Any chronic issues? IE: physical pain or autoimmune disorders. If yes, please explain*

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Are you pregnant, breast feeding or on any hormone therapy? If yes, please explain*

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Have you received any of the covid vaccines? If yes, please tell us how many and if you have experienced any negative side effects*

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Have you sat with plant medicines in the past? If yes, please elaborate*

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Are you currently taking any prescription medications? If yes, please list all medications, dosages and what you are taking it for*

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Are you currently taking any vitamins, minerals or supplements? If yes, please explain what you are taking, what dose and what you are taking it for*

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Are you currently using recreational substances? If yes, please list all substances and tell us when you last used*

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Do you have any allergies? If yes, please explain and let us know if you require an epipen*

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Do you have dietary restrictions? If yes, please explain*

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Is there anything we should know about your mental, emotional or physical health and overall well-being that we have not asked to determine if these ceremonies are safe for you?*

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Please tell us a bit about you. Describe yourself in three words. What is your outlook on life. Do you believe you are enough and worthy? *

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What are your intentions for seeking holistic treatments?*

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Date Preference*

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I hereby understand and agree that the data I have provided will be used and processed for the purpose of ensuring I am medically and emotionally safe to proceed with alternative healing modalities with Kambo VIP. I acknowledge that I am signing this form of my own free-will and hold no liability to Kambo VIP, their practitioners or other participants in regards to my mental health and physical well-being. I have been made aware of the potential side effects and accept full responsibility of negative outcomes in the event that I have provided false or misleading information that is detrimental to the acceptance of my application for participation. I understand that photography is occasional used for the purpose of advertisements during ceremony, but that my identity will remain anonymous. I understand that my participation is pending approval of this medical information form.*

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