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Client Intake Form

Thank you for taking the necessary time to complete our intake form. The information you provide helps create a safe, supportive, and personalized experience. Please answer all questions honestly and thoroughly. All information shared is kept confidential and used solely to assess safety, preparedness, and appropriate care. If you are unsure about any question, please answer to the best of your ability. 

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Are you currently pregnant or possibly pregnant?
Are you currently breastfeeding?
Do you have Addison’s Disease or adrenal insufficiency?
Do you have Ehlers Danlos Syndrome?
Have you ever had a stroke, aneurysm, brain hemorrhage, or blood clot?
Do you have a diagnosed heart condition or significant cardiovascular issue?
Do you currently take medication for blood pressure or heart-related conditions?
Have you ever had an organ transplant and/or are you taking any immune suppressants?
Are you currently undergoing chemotherapy/radiotherapy or treatment for a serious medical condition?
Have you experienced seizures or been diagnosed with epilepsy?
Do you have any serious mental health conditions that may affect your ability to participate safely?
Have you had any recent surgeries or major medical procedures within the last 6 months?
Are you currently experiencing any acute illness, infection, fever, or severe physical symptoms?
Have you taken any vaccinations recently?
Do you currently consume alcohol?
Do you currently use recreational or non-prescribed substances?
Have you previously worked with Kambo?
Have you participated in other plant medicine, ceremonial, detox, or intensive healing practices before?

Kambo Informed Consent & Liability Waiver 

1. I acknowledge that I am voluntarily participating in a Kambo session and understand that Kambo is a traditional cleansing practice involving the secretion of the Giant Monkey Frog, Phyllomedusa bicolor. I understand that Kambo is not intended to diagnose, treat, cure, or prevent any disease and is not a substitute for medical care. 

2. I understand that Kambo is an intense cleansing practice that may involve temporary physical, emotional, and energetic discomfort. I understand that possible reactions and side effects may include, but are not limited to vomiting, sweating, swelling. increased heart rate, flushing, dizziness, diarrhea, fatigue, temporary changes in blood pressure, emotional release and heightened emotions. 

3. I understand that reactions vary from person to person and that no guarantees or promises regarding outcomes or benefits have been made. 

4. I understand that withholding important medical information may increase the risk of complications. 

5. I understand that I am responsible for consulting a licensed physician regarding any medical concerns or contraindications. 

6. I understand that I may stop the session at any time and that participation is completely voluntary. 

7. I acknowledge that participation in Kambo carries inherent risks. 

8. I voluntarily assume full responsibility for any risks, injuries, damages, or losses that may occur as a result of participating in this session. 

9. I release and hold harmless the practitioner, facilitators, assistants, property owners, business entities, and affiliates from any and all liability, claims, demands, damages, actions, causes of action, or expenses arising out of or related to my participation. 

10. I understand that the practitioner is not acting as a licensed medical doctor. 

11. I certify that I am at least 18 years of age and legally capable of signing this agreement. 

12. I understand that this agreement is intended to be as broad and inclusive as permitted by applicable law. 

13. I affirm that I have disclosed all known medical conditions, medications, supplements, allergies, and relevant health information honestly and completely. 

I confirm that the information provided in this intake form is true and accurate to the best of my knowledge. Further, I acknowledge that I have carefully read and fully understand this Informed Consent and Liability Waiver. 

I voluntarily agree to participate in the Kambo session under the terms stated above. 

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