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? (if yes, please describe shortly)

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?

heart problems

cardiovascular diseases

blood clots

abnormal or high blood pressure

experience of chest pains, dizziness or fainting

organ transplant

blood borne diseases such as Hepatitis or HIV

anorexia or obesity

non of the above

do you have any major operations planed 1 month post or prior to the session?

yes

no

are you on any medications?(If yes, please state which and for how long. includes prescriptive drugs or any self-medication)

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

is there anything else you want me to know about yourself?

I will take the advised preparation for the session seriously.(which includes keeping of alcohol and recreational drugs for at least a week and at least 8 hour fasting prior to the session)

yes

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.

yes

I understand that Anna Gottwald is not a professional medical doctor, psychotherapist or legal adviser and that all actions I take, due to advice or suggestions during the session, are my own responsibility.

I understand that Anna Gottwald is not a professional medical doctor, psychotherapist or legal adviser and that all actions I take, due to advice or suggestions during the session, are my own responsibility.

yes