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Kambo application form

name

*

adress

*

email

*

phone number

date of birth

*

why do you want to do a kambo ceremony?

*

what do you expect from the session?

*

have you done kambo before?

*

do you have experience with any other sacred medicines? (if so, please describe shortly)

do you HAVE or HAD any of the following physical conditions?

*

do you HAVE or HAD any of the following physical conditions?

heart problems

cardiovascular diseases

abnormal blood pressure

anorexia or obesity

non of the above

do you have any psychic conditions, EXCEPT anxiety, depression or PTSD?

*

I understand that the kambo ceremony is no substitute for necessary physical or psychological treatment.

*

I understand that the kambo ceremony is no substitute for necessary physical or psychological treatment.

yes

I understand and give my consent to, that during the ceremony I will receive surficial burning marks, that can leave scars.

*

I understand and give my consent to, that during the ceremony I will receive surficial burning marks, that can leave scars.

yes