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CONTRAINDICATIONS, WAIVER AND RELEASE AGREEMENT

Please take your time and review all six pages of this document carefully.

PRACTITIONER INFO

This waiver and agreement is for clients who work with Emily Johnson, and or Michael Johnson. Tribal Detox Practitioners in Loving, Texas, U.S.A.

PURPOSE AND USE OF KAMBO

Kambo is a traditional Amazonian medicine that involves applying the secretion of the Phyllomedusa bicolor frog to small burns on the skin. It is a non-psychoactive substance used by various cultures in healing practices.

CONTRAINDICATION AGREEMENT

Clients must not take Kambo if any of the following apply. By checking each box, you confirm you do NOT have any of these conditions:

Serious heart problems

I Agree
 

Being on a no-salt diet (ayahuasca diet)

I Agree
 

Ehlers Danlos or Marfan syndrome

I Agree
 

Medication for low blood pressure 

I Agree
 

History of stroke, brain hemorrhage, or blood clots 

I Agree
 

Lack the mental capacity to consent 

I Agree
 

Serious mental health issues (excluding depression, PTSD, and anxiety) 

I Agree
 

Undergoing chemotherapy, radiotherapy, or immunotherapy (6 weeks exclusion) 

I Agree
 

Use of immune-suppressants for organ transplant

I Agree
 

Addison's Disease 

I Agree
 

Current or severe epilepsy 

I Agree

Recovering from major surgery 

I Agree
 

Under 18 years old 

I Agree
 

Pregnancy or breastfeeding 

I Agree
 

Daily diuretic medication 

I Agree
 

Consumption of other strong medicines within 24 hours (Ayahuasca, San Pedro, Mushrooms) 

I Agree
 

Recent Covid Vaccine (4-week exclusion) 

I Agree
 

Reached 70th birthday 

I Agree
 

Fasting for longer than 18 hours 

I Agree
 

SUBSTANCE GUIDELINE LIST

The following substances should be abstained before and after a Kambo session. Please confirm your understanding and that you AGREE to the abstinence period by checking the box next to each substance.

Alcohol (High Doses): 48 hours before / 7 days after

I Agree

Alcohol (Low Doses): 12 hours before / 24 hours after

I Agree

Amphetamines (Adderall, Ritalin): 7 days before / 7 days after

I Agree

Anti-Convulsants: Must discuss with facilitator

I Agree

Anti-Psychotics: Contraindicated

I Agree

Ayahuasca & Analogues: 24 hours before / 24 hours after

I Agree

Benzodiazepines (Valium, Diazepam): 18 hours before / 8 hours after

I Agree

Beta Blockers: Do not take the morning of your session / 8 hours after

I Agree

Blood Thinners: Do not take the morning of your session / 8 hours after

I Agree

Botox: 7 days before / 7 days after

I Agree

Cannabis: 12 hours before / 24 hours after

I Agree

Cocaine: 3 days before / 5 days after

I Agree

Crack Cocaine: 7 days before / 7 days after

I Agree

Ecstasy (MDMA): 7 days before / 7 days after

I Agree

Fentanyl: Contraindicated

I Agree

Heroin: 14 days before / 14 days after

I Agree

Meth Amphetamine: 30 days before / 30 days after

I Agree

Morphine/Oxycodone: 5 days before / 5 days after

I Agree

LSD: 48 hours before / 72 hours after

I Agree

Psilocybin: 24 hours before / 24 hours after

I Agree

Tramadol: 48 hours before / 24 hours after

I Agree

Vasoconstrictors (Triptans): 3 days before / 12 hours after

I Agree

Covid Vaccine: 30 days before / 7 days after

I Agree

INFORMED CONSENT

By checking this box, you acknowledge that you have been informed about Kambo, had the opportunity to ask questions, and understand the benefits and potential risks. 

I Agree

MEDICAL HISTORY DISCLOSURE

By checking this box, you AGREE to disclose any and all relevant medical history, medications, or health conditions that could affect your session.

I Agree

EMERGENCY MEDICAL TREATMENT

By checking this box, you AGREE to allow your practitioner to seek emergency medical support and/or treatment for you if necessary, and you AGREE to cover any related costs.

I Agree

LIABILITY RELEASE AND ASSUMPTION OF RISK

This waiver includes a comprehensive release of liability clause, stating that the participant AGREES to participate voluntarily and assumes full responsibility for any and all outcomes. The practitioner and the Kambo Contraindications, Waiver and Release Agreement, and the organizations with whom they are affiliated, are released of any liability and completely absolved of all responsibility for any and all potential injuries (physical or psychological) or death resulting from participation in a Kambo session, regardless of circumstances or disclosed health information. The participant acknowledges and AGREES that they are voluntarily engaging in this practice at their own risk.

INDEMNIFICATION

Participant agrees to indemnify, defend, and hold harmless Emily and Michael Johnson, its affiliates, employees, agents, and representatives from and against any and all claims, liabilities, damages, losses, costs, or expenses, including reasonable attorney's fees, arising out of or related to the Participant’s participation in Kambo treatments. This includes, but is not limited to, any and all claims resulting from personal injury, emotional distress, or any adverse reactions that may occur during or after the treatment.

CANCELATION POLICY

Full refunds will only be offered with seven days' notice of cancelation (unless discussed and agreed upon by the practitioner.) Partial refunds may be provided with five days’ notice of cancelation. No refunds are offered for no-shows or cancelations with less than five days’ notice.

GOVERNING LAW

This Waiver and Release shall be governed by and construed in accordance with, the laws of the State of Texas, without regard to its conflict of law principles. Any disputes arising out of or relating to this Waiver shall be resolved exclusively in the courts located within Young County, Texas.

AGREEMENT AND SIGNATURE

By signing below, you confirm that you have read, understood, and agree to the terms outlined in this document and that you are participating voluntarily in the Kambo session.


Today's Date: September 14, 2026


www.tribaldetox.com / www.lovingkambo.net

First Client's Name
First Name*
Last Name*
Phone*
First Client's Date of Birth*
Date of Birth
First Client's Signature*
Second Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Third Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Fourth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Fifth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Sixth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Seventh Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Eighth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Ninth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Tenth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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