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Kambo Waiver & Contraindications Agreement

I.  Practitioner Information

Name: Stacey Rohr

Business Name: LionHeart Healing Arts 

Location: Wimberley, TX USA

II.  Purpose and Use of Kambo

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

III. Contraindication Agreement

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

I Agree
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

IV. Substance Guideline List

The following substances should be abstained from before and after a Kambo session. Please confirm your agreement to each abstinence period by checking each box:

I Agree
 Alcohol (High Doses): 48 Hours / 7 Days

I Agree
 Alcohol (Low Doses): 12 Hours / 24 Hours

I Agree
 Amphetamines (Adderall, Ritalin): 7 Days / 7 Days

I Agree
 Anti-Convulsants: Must discuss with facilitator

I Agree
 Anti-Psychotics: Contraindicated

I Agree
 Ayahuasca & Analogues: 24 Hours / 24 Hours

I Agree
 Benzodiazepines (Valium, Diazepam): 18 Hours / 8 Hours

I Agree
 Beta Blockers: Do not take morning of treatment / 8 Hours

I Agree
 Blood Thinners: Do not take morning of treatment / 8 Hours

I Agree
 Botox: 7 Days / 7 Days

I Agree
 Cannabis: 12 Hours / 24 Hours

I Agree
 Cocaine: 3 Days / 5 Days

I Agree
 Crack Cocaine: 7 Days / 7 Days

I Agree
 Ecstasy (MDMA): 7 Days / 7 Days

I Agree
 Fentanyl: Contraindicated

I Agree
 Heroin: 14 Days / 14 Days

I Agree
 Meth Amphetamine: 30 Days / 30 Days

I Agree
 Morphine/Oxycodone: 5 Days / 5 Days

I Agree
 LSD: 48 Hours / 72 Hours

I Agree
 Psilocybin: 24 Hours / 24 Hours

I Agree
 Tramadol: 48 Hours / 24 Hours

I Agree
 Vasoconstrictors (Triptans): 3 Days / 12 Hours

I Agree
 Covid Vaccine: 30 Days / 7 Days

 V. 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 outcome. The practitioner and the Kambo Waiver & Contraindications Agreement are absolved of all responsibility for any potential injuries (physical or psychological) or death resulting from participation in a Kambo session, regardless of circumstances or disclosed health information. The participant acknowledges that they are voluntarily engaging in this practice at their own risk.

Agreement and Signature

This waiver is a legally binding document. 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 ceremony.  

First Participant's Name
First Name*
Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Last Name*
Participant'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.
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 Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
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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