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Kambo Contraindications,

waiver and release

agreement

Please take your time and review the entire document carefully. 

I. Practitioner info

This waiver and agreement is for clients who work with Elizabeth Sanderson/Soul Body Evolution, a Tribal Detox Kambo Practitioner located in Virginia.

II. Purpose and use of Kambo

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

III. 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.

IV. Indemnification 

Participant agrees to indemnify, defend, and hold harmless Elizabeth Sanderson/Soul Body Evolution, 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 participants 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. 

V. Cancellation Policy

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

VI. Governing Law

This waiver and release shall be governed by and construed in accordance with, the laws of the sate of Virginia, without regard to its conflict of law priciples. Any disputes arising out of or relating to this waiver shall be resolved exclusively in the courts located within Virginia.

VII. 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.


First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
Information
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
Being on a no-salt diet (ayahuasca diet)
Ehlers Danlos or Marfan syndrome
Medication for low blood pressure
History of stroke, brain hemorrhage, or blood clots
Lack the mental capacity to consent
Serious mental health issues (excluding depression, PTSD, and axiety)
Undergoing chemotherapy, radiotherapy, or immunotherapy (6 weeks exclusion)
Use of immune-supressants for organ transplant
Addison's disease
Current or severe epilepsy
Recovering from major surgery
Under 18 years old
Pregnant or breastfeeding
Daily diuretic medication
Consumption of other strong medicines within 24 hours (Ayahuasca, San Pedro, Mushrooms)
Recent Covid Vaccine (4-week exclusion)
Reached 70th birthday
Fasting for longer than 18 hours
SUBSTANCE GUIDELINE LIST: The following substances should be abstained before and after a Kambo session. Please confirm your understanding that you AGREE to the abstinence period by checking the box next to each substance. *
Alcohol (high doses): 48 hours before/ 7 days after
Alcohol (low doses): 12 hours before/ 24 hours after
Amphetamines (Adderall, Ritalin): 7 days before/ 7 days after
Anti-convulsants: must discuss with facilitator
Anti-Psychotics: Contraindicated
Ayahuasca & Analogues: 24 hours before/ 24 hours after
Benzodiazepines (Valium, Diazepam): 18 hours before/ 8 hours after
Beta Blockers: Do not take the morning of your session/ 8 hours after
Blood thinners: Do not take the morning of your session/ 8 hours after
Botox: 7 days before/ 7 days after
Cannabis: 12 hours before/ 24 hours after
Cocaine: 3 days before/ 5 days after
Crack Cocaine: 7 days before/ 7 days after
Ecstacy (MDMA): 7 days before/ 7 days after
Fentanyl: Contraindicated
Heroin: 14 days before/ 14 days after
Meth Amphetamine: 30 days before/ 30 days after
Morphine/Oxycodone: 5 days before/ 5 days after
LSD: 48 hours before/ 72 hours after
Psilocybin: 24 hours before/ 24 hours after
Tramadol: 48 hours before/ 24 hours after
Vasoconstrictors (Triptans): 3 days before/ 12 hours after
Covid Vaccine: 30 days before/ 7 days after
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

Please list any and all medications and/or supplements you are currently taking: *
INFORMED CONSENT: *
By Checking this box, you AGREE to disclose any and all relevant medical history, medications, or health conditions that could affect your session
EMERGENCY MEDICAL TREATMENT:
By checking this box, you AGREE to allow your practtioner to seek emergency medical support and/or treatment for you if necessary, and you AGREE to cover any and all related costs
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
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
Being on a no-salt diet (ayahuasca diet)
Ehlers Danlos or Marfan syndrome
Medication for low blood pressure
History of stroke, brain hemorrhage, or blood clots
Lack the mental capacity to consent
Serious mental health issues (excluding depression, PTSD, and axiety)
Undergoing chemotherapy, radiotherapy, or immunotherapy (6 weeks exclusion)
Use of immune-supressants for organ transplant
Addison's disease
Current or severe epilepsy
Recovering from major surgery
Under 18 years old
Pregnant or breastfeeding
Daily diuretic medication
Consumption of other strong medicines within 24 hours (Ayahuasca, San Pedro, Mushrooms)
Recent Covid Vaccine (4-week exclusion)
Reached 70th birthday
Fasting for longer than 18 hours
SUBSTANCE GUIDELINE LIST: The following substances should be abstained before and after a Kambo session. Please confirm your understanding that you AGREE to the abstinence period by checking the box next to each substance. *
Alcohol (high doses): 48 hours before/ 7 days after
Alcohol (low doses): 12 hours before/ 24 hours after
Amphetamines (Adderall, Ritalin): 7 days before/ 7 days after
Anti-convulsants: must discuss with facilitator
Anti-Psychotics: Contraindicated
Ayahuasca & Analogues: 24 hours before/ 24 hours after
Benzodiazepines (Valium, Diazepam): 18 hours before/ 8 hours after
Beta Blockers: Do not take the morning of your session/ 8 hours after
Blood thinners: Do not take the morning of your session/ 8 hours after
Botox: 7 days before/ 7 days after
Cannabis: 12 hours before/ 24 hours after
Cocaine: 3 days before/ 5 days after
Crack Cocaine: 7 days before/ 7 days after
Ecstacy (MDMA): 7 days before/ 7 days after
Fentanyl: Contraindicated
Heroin: 14 days before/ 14 days after
Meth Amphetamine: 30 days before/ 30 days after
Morphine/Oxycodone: 5 days before/ 5 days after
LSD: 48 hours before/ 72 hours after
Psilocybin: 24 hours before/ 24 hours after
Tramadol: 48 hours before/ 24 hours after
Vasoconstrictors (Triptans): 3 days before/ 12 hours after
Covid Vaccine: 30 days before/ 7 days after
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

Please list any and all medications and/or supplements you are currently taking: *
INFORMED CONSENT: *
By Checking this box, you AGREE to disclose any and all relevant medical history, medications, or health conditions that could affect your session
EMERGENCY MEDICAL TREATMENT:
By checking this box, you AGREE to allow your practtioner to seek emergency medical support and/or treatment for you if necessary, and you AGREE to cover any and all related costs
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
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
Being on a no-salt diet (ayahuasca diet)
Ehlers Danlos or Marfan syndrome
Medication for low blood pressure
History of stroke, brain hemorrhage, or blood clots
Lack the mental capacity to consent
Serious mental health issues (excluding depression, PTSD, and axiety)
Undergoing chemotherapy, radiotherapy, or immunotherapy (6 weeks exclusion)
Use of immune-supressants for organ transplant
Addison's disease
Current or severe epilepsy
Recovering from major surgery
Under 18 years old
Pregnant or breastfeeding
Daily diuretic medication
Consumption of other strong medicines within 24 hours (Ayahuasca, San Pedro, Mushrooms)
Recent Covid Vaccine (4-week exclusion)
Reached 70th birthday
Fasting for longer than 18 hours
SUBSTANCE GUIDELINE LIST: The following substances should be abstained before and after a Kambo session. Please confirm your understanding that you AGREE to the abstinence period by checking the box next to each substance. *
Alcohol (high doses): 48 hours before/ 7 days after
Alcohol (low doses): 12 hours before/ 24 hours after
Amphetamines (Adderall, Ritalin): 7 days before/ 7 days after
Anti-convulsants: must discuss with facilitator
Anti-Psychotics: Contraindicated
Ayahuasca & Analogues: 24 hours before/ 24 hours after
Benzodiazepines (Valium, Diazepam): 18 hours before/ 8 hours after
Beta Blockers: Do not take the morning of your session/ 8 hours after
Blood thinners: Do not take the morning of your session/ 8 hours after
Botox: 7 days before/ 7 days after
Cannabis: 12 hours before/ 24 hours after
Cocaine: 3 days before/ 5 days after
Crack Cocaine: 7 days before/ 7 days after
Ecstacy (MDMA): 7 days before/ 7 days after
Fentanyl: Contraindicated
Heroin: 14 days before/ 14 days after
Meth Amphetamine: 30 days before/ 30 days after
Morphine/Oxycodone: 5 days before/ 5 days after
LSD: 48 hours before/ 72 hours after
Psilocybin: 24 hours before/ 24 hours after
Tramadol: 48 hours before/ 24 hours after
Vasoconstrictors (Triptans): 3 days before/ 12 hours after
Covid Vaccine: 30 days before/ 7 days after
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

Please list any and all medications and/or supplements you are currently taking: *
INFORMED CONSENT: *
By Checking this box, you AGREE to disclose any and all relevant medical history, medications, or health conditions that could affect your session
EMERGENCY MEDICAL TREATMENT:
By checking this box, you AGREE to allow your practtioner to seek emergency medical support and/or treatment for you if necessary, and you AGREE to cover any and all related costs
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
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
Being on a no-salt diet (ayahuasca diet)
Ehlers Danlos or Marfan syndrome
Medication for low blood pressure
History of stroke, brain hemorrhage, or blood clots
Lack the mental capacity to consent
Serious mental health issues (excluding depression, PTSD, and axiety)
Undergoing chemotherapy, radiotherapy, or immunotherapy (6 weeks exclusion)
Use of immune-supressants for organ transplant
Addison's disease
Current or severe epilepsy
Recovering from major surgery
Under 18 years old
Pregnant or breastfeeding
Daily diuretic medication
Consumption of other strong medicines within 24 hours (Ayahuasca, San Pedro, Mushrooms)
Recent Covid Vaccine (4-week exclusion)
Reached 70th birthday
Fasting for longer than 18 hours
SUBSTANCE GUIDELINE LIST: The following substances should be abstained before and after a Kambo session. Please confirm your understanding that you AGREE to the abstinence period by checking the box next to each substance. *
Alcohol (high doses): 48 hours before/ 7 days after
Alcohol (low doses): 12 hours before/ 24 hours after
Amphetamines (Adderall, Ritalin): 7 days before/ 7 days after
Anti-convulsants: must discuss with facilitator
Anti-Psychotics: Contraindicated
Ayahuasca & Analogues: 24 hours before/ 24 hours after
Benzodiazepines (Valium, Diazepam): 18 hours before/ 8 hours after
Beta Blockers: Do not take the morning of your session/ 8 hours after
Blood thinners: Do not take the morning of your session/ 8 hours after
Botox: 7 days before/ 7 days after
Cannabis: 12 hours before/ 24 hours after
Cocaine: 3 days before/ 5 days after
Crack Cocaine: 7 days before/ 7 days after
Ecstacy (MDMA): 7 days before/ 7 days after
Fentanyl: Contraindicated
Heroin: 14 days before/ 14 days after
Meth Amphetamine: 30 days before/ 30 days after
Morphine/Oxycodone: 5 days before/ 5 days after
LSD: 48 hours before/ 72 hours after
Psilocybin: 24 hours before/ 24 hours after
Tramadol: 48 hours before/ 24 hours after
Vasoconstrictors (Triptans): 3 days before/ 12 hours after
Covid Vaccine: 30 days before/ 7 days after
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

Please list any and all medications and/or supplements you are currently taking: *
INFORMED CONSENT: *
By Checking this box, you AGREE to disclose any and all relevant medical history, medications, or health conditions that could affect your session
EMERGENCY MEDICAL TREATMENT:
By checking this box, you AGREE to allow your practtioner to seek emergency medical support and/or treatment for you if necessary, and you AGREE to cover any and all related costs
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
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
Being on a no-salt diet (ayahuasca diet)
Ehlers Danlos or Marfan syndrome
Medication for low blood pressure
History of stroke, brain hemorrhage, or blood clots
Lack the mental capacity to consent
Serious mental health issues (excluding depression, PTSD, and axiety)
Undergoing chemotherapy, radiotherapy, or immunotherapy (6 weeks exclusion)
Use of immune-supressants for organ transplant
Addison's disease
Current or severe epilepsy
Recovering from major surgery
Under 18 years old
Pregnant or breastfeeding
Daily diuretic medication
Consumption of other strong medicines within 24 hours (Ayahuasca, San Pedro, Mushrooms)
Recent Covid Vaccine (4-week exclusion)
Reached 70th birthday
Fasting for longer than 18 hours
SUBSTANCE GUIDELINE LIST: The following substances should be abstained before and after a Kambo session. Please confirm your understanding that you AGREE to the abstinence period by checking the box next to each substance. *
Alcohol (high doses): 48 hours before/ 7 days after
Alcohol (low doses): 12 hours before/ 24 hours after
Amphetamines (Adderall, Ritalin): 7 days before/ 7 days after
Anti-convulsants: must discuss with facilitator
Anti-Psychotics: Contraindicated
Ayahuasca & Analogues: 24 hours before/ 24 hours after
Benzodiazepines (Valium, Diazepam): 18 hours before/ 8 hours after
Beta Blockers: Do not take the morning of your session/ 8 hours after
Blood thinners: Do not take the morning of your session/ 8 hours after
Botox: 7 days before/ 7 days after
Cannabis: 12 hours before/ 24 hours after
Cocaine: 3 days before/ 5 days after
Crack Cocaine: 7 days before/ 7 days after
Ecstacy (MDMA): 7 days before/ 7 days after
Fentanyl: Contraindicated
Heroin: 14 days before/ 14 days after
Meth Amphetamine: 30 days before/ 30 days after
Morphine/Oxycodone: 5 days before/ 5 days after
LSD: 48 hours before/ 72 hours after
Psilocybin: 24 hours before/ 24 hours after
Tramadol: 48 hours before/ 24 hours after
Vasoconstrictors (Triptans): 3 days before/ 12 hours after
Covid Vaccine: 30 days before/ 7 days after
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

Please list any and all medications and/or supplements you are currently taking: *
INFORMED CONSENT: *
By Checking this box, you AGREE to disclose any and all relevant medical history, medications, or health conditions that could affect your session
EMERGENCY MEDICAL TREATMENT:
By checking this box, you AGREE to allow your practtioner to seek emergency medical support and/or treatment for you if necessary, and you AGREE to cover any and all related costs
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
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
Being on a no-salt diet (ayahuasca diet)
Ehlers Danlos or Marfan syndrome
Medication for low blood pressure
History of stroke, brain hemorrhage, or blood clots
Lack the mental capacity to consent
Serious mental health issues (excluding depression, PTSD, and axiety)
Undergoing chemotherapy, radiotherapy, or immunotherapy (6 weeks exclusion)
Use of immune-supressants for organ transplant
Addison's disease
Current or severe epilepsy
Recovering from major surgery
Under 18 years old
Pregnant or breastfeeding
Daily diuretic medication
Consumption of other strong medicines within 24 hours (Ayahuasca, San Pedro, Mushrooms)
Recent Covid Vaccine (4-week exclusion)
Reached 70th birthday
Fasting for longer than 18 hours
SUBSTANCE GUIDELINE LIST: The following substances should be abstained before and after a Kambo session. Please confirm your understanding that you AGREE to the abstinence period by checking the box next to each substance. *
Alcohol (high doses): 48 hours before/ 7 days after
Alcohol (low doses): 12 hours before/ 24 hours after
Amphetamines (Adderall, Ritalin): 7 days before/ 7 days after
Anti-convulsants: must discuss with facilitator
Anti-Psychotics: Contraindicated
Ayahuasca & Analogues: 24 hours before/ 24 hours after
Benzodiazepines (Valium, Diazepam): 18 hours before/ 8 hours after
Beta Blockers: Do not take the morning of your session/ 8 hours after
Blood thinners: Do not take the morning of your session/ 8 hours after
Botox: 7 days before/ 7 days after
Cannabis: 12 hours before/ 24 hours after
Cocaine: 3 days before/ 5 days after
Crack Cocaine: 7 days before/ 7 days after
Ecstacy (MDMA): 7 days before/ 7 days after
Fentanyl: Contraindicated
Heroin: 14 days before/ 14 days after
Meth Amphetamine: 30 days before/ 30 days after
Morphine/Oxycodone: 5 days before/ 5 days after
LSD: 48 hours before/ 72 hours after
Psilocybin: 24 hours before/ 24 hours after
Tramadol: 48 hours before/ 24 hours after
Vasoconstrictors (Triptans): 3 days before/ 12 hours after
Covid Vaccine: 30 days before/ 7 days after
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

Please list any and all medications and/or supplements you are currently taking: *
INFORMED CONSENT: *
By Checking this box, you AGREE to disclose any and all relevant medical history, medications, or health conditions that could affect your session
EMERGENCY MEDICAL TREATMENT:
By checking this box, you AGREE to allow your practtioner to seek emergency medical support and/or treatment for you if necessary, and you AGREE to cover any and all related costs
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
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
Being on a no-salt diet (ayahuasca diet)
Ehlers Danlos or Marfan syndrome
Medication for low blood pressure
History of stroke, brain hemorrhage, or blood clots
Lack the mental capacity to consent
Serious mental health issues (excluding depression, PTSD, and axiety)
Undergoing chemotherapy, radiotherapy, or immunotherapy (6 weeks exclusion)
Use of immune-supressants for organ transplant
Addison's disease
Current or severe epilepsy
Recovering from major surgery
Under 18 years old
Pregnant or breastfeeding
Daily diuretic medication
Consumption of other strong medicines within 24 hours (Ayahuasca, San Pedro, Mushrooms)
Recent Covid Vaccine (4-week exclusion)
Reached 70th birthday
Fasting for longer than 18 hours
SUBSTANCE GUIDELINE LIST: The following substances should be abstained before and after a Kambo session. Please confirm your understanding that you AGREE to the abstinence period by checking the box next to each substance. *
Alcohol (high doses): 48 hours before/ 7 days after
Alcohol (low doses): 12 hours before/ 24 hours after
Amphetamines (Adderall, Ritalin): 7 days before/ 7 days after
Anti-convulsants: must discuss with facilitator
Anti-Psychotics: Contraindicated
Ayahuasca & Analogues: 24 hours before/ 24 hours after
Benzodiazepines (Valium, Diazepam): 18 hours before/ 8 hours after
Beta Blockers: Do not take the morning of your session/ 8 hours after
Blood thinners: Do not take the morning of your session/ 8 hours after
Botox: 7 days before/ 7 days after
Cannabis: 12 hours before/ 24 hours after
Cocaine: 3 days before/ 5 days after
Crack Cocaine: 7 days before/ 7 days after
Ecstacy (MDMA): 7 days before/ 7 days after
Fentanyl: Contraindicated
Heroin: 14 days before/ 14 days after
Meth Amphetamine: 30 days before/ 30 days after
Morphine/Oxycodone: 5 days before/ 5 days after
LSD: 48 hours before/ 72 hours after
Psilocybin: 24 hours before/ 24 hours after
Tramadol: 48 hours before/ 24 hours after
Vasoconstrictors (Triptans): 3 days before/ 12 hours after
Covid Vaccine: 30 days before/ 7 days after
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

Please list any and all medications and/or supplements you are currently taking: *
INFORMED CONSENT: *
By Checking this box, you AGREE to disclose any and all relevant medical history, medications, or health conditions that could affect your session
EMERGENCY MEDICAL TREATMENT:
By checking this box, you AGREE to allow your practtioner to seek emergency medical support and/or treatment for you if necessary, and you AGREE to cover any and all related costs
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
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
Being on a no-salt diet (ayahuasca diet)
Ehlers Danlos or Marfan syndrome
Medication for low blood pressure
History of stroke, brain hemorrhage, or blood clots
Lack the mental capacity to consent
Serious mental health issues (excluding depression, PTSD, and axiety)
Undergoing chemotherapy, radiotherapy, or immunotherapy (6 weeks exclusion)
Use of immune-supressants for organ transplant
Addison's disease
Current or severe epilepsy
Recovering from major surgery
Under 18 years old
Pregnant or breastfeeding
Daily diuretic medication
Consumption of other strong medicines within 24 hours (Ayahuasca, San Pedro, Mushrooms)
Recent Covid Vaccine (4-week exclusion)
Reached 70th birthday
Fasting for longer than 18 hours
SUBSTANCE GUIDELINE LIST: The following substances should be abstained before and after a Kambo session. Please confirm your understanding that you AGREE to the abstinence period by checking the box next to each substance. *
Alcohol (high doses): 48 hours before/ 7 days after
Alcohol (low doses): 12 hours before/ 24 hours after
Amphetamines (Adderall, Ritalin): 7 days before/ 7 days after
Anti-convulsants: must discuss with facilitator
Anti-Psychotics: Contraindicated
Ayahuasca & Analogues: 24 hours before/ 24 hours after
Benzodiazepines (Valium, Diazepam): 18 hours before/ 8 hours after
Beta Blockers: Do not take the morning of your session/ 8 hours after
Blood thinners: Do not take the morning of your session/ 8 hours after
Botox: 7 days before/ 7 days after
Cannabis: 12 hours before/ 24 hours after
Cocaine: 3 days before/ 5 days after
Crack Cocaine: 7 days before/ 7 days after
Ecstacy (MDMA): 7 days before/ 7 days after
Fentanyl: Contraindicated
Heroin: 14 days before/ 14 days after
Meth Amphetamine: 30 days before/ 30 days after
Morphine/Oxycodone: 5 days before/ 5 days after
LSD: 48 hours before/ 72 hours after
Psilocybin: 24 hours before/ 24 hours after
Tramadol: 48 hours before/ 24 hours after
Vasoconstrictors (Triptans): 3 days before/ 12 hours after
Covid Vaccine: 30 days before/ 7 days after
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

Please list any and all medications and/or supplements you are currently taking: *
INFORMED CONSENT: *
By Checking this box, you AGREE to disclose any and all relevant medical history, medications, or health conditions that could affect your session
EMERGENCY MEDICAL TREATMENT:
By checking this box, you AGREE to allow your practtioner to seek emergency medical support and/or treatment for you if necessary, and you AGREE to cover any and all related costs
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
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
Being on a no-salt diet (ayahuasca diet)
Ehlers Danlos or Marfan syndrome
Medication for low blood pressure
History of stroke, brain hemorrhage, or blood clots
Lack the mental capacity to consent
Serious mental health issues (excluding depression, PTSD, and axiety)
Undergoing chemotherapy, radiotherapy, or immunotherapy (6 weeks exclusion)
Use of immune-supressants for organ transplant
Addison's disease
Current or severe epilepsy
Recovering from major surgery
Under 18 years old
Pregnant or breastfeeding
Daily diuretic medication
Consumption of other strong medicines within 24 hours (Ayahuasca, San Pedro, Mushrooms)
Recent Covid Vaccine (4-week exclusion)
Reached 70th birthday
Fasting for longer than 18 hours
SUBSTANCE GUIDELINE LIST: The following substances should be abstained before and after a Kambo session. Please confirm your understanding that you AGREE to the abstinence period by checking the box next to each substance. *
Alcohol (high doses): 48 hours before/ 7 days after
Alcohol (low doses): 12 hours before/ 24 hours after
Amphetamines (Adderall, Ritalin): 7 days before/ 7 days after
Anti-convulsants: must discuss with facilitator
Anti-Psychotics: Contraindicated
Ayahuasca & Analogues: 24 hours before/ 24 hours after
Benzodiazepines (Valium, Diazepam): 18 hours before/ 8 hours after
Beta Blockers: Do not take the morning of your session/ 8 hours after
Blood thinners: Do not take the morning of your session/ 8 hours after
Botox: 7 days before/ 7 days after
Cannabis: 12 hours before/ 24 hours after
Cocaine: 3 days before/ 5 days after
Crack Cocaine: 7 days before/ 7 days after
Ecstacy (MDMA): 7 days before/ 7 days after
Fentanyl: Contraindicated
Heroin: 14 days before/ 14 days after
Meth Amphetamine: 30 days before/ 30 days after
Morphine/Oxycodone: 5 days before/ 5 days after
LSD: 48 hours before/ 72 hours after
Psilocybin: 24 hours before/ 24 hours after
Tramadol: 48 hours before/ 24 hours after
Vasoconstrictors (Triptans): 3 days before/ 12 hours after
Covid Vaccine: 30 days before/ 7 days after
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

Please list any and all medications and/or supplements you are currently taking: *
INFORMED CONSENT: *
By Checking this box, you AGREE to disclose any and all relevant medical history, medications, or health conditions that could affect your session
EMERGENCY MEDICAL TREATMENT:
By checking this box, you AGREE to allow your practtioner to seek emergency medical support and/or treatment for you if necessary, and you AGREE to cover any and all related costs
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
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
Being on a no-salt diet (ayahuasca diet)
Ehlers Danlos or Marfan syndrome
Medication for low blood pressure
History of stroke, brain hemorrhage, or blood clots
Lack the mental capacity to consent
Serious mental health issues (excluding depression, PTSD, and axiety)
Undergoing chemotherapy, radiotherapy, or immunotherapy (6 weeks exclusion)
Use of immune-supressants for organ transplant
Addison's disease
Current or severe epilepsy
Recovering from major surgery
Under 18 years old
Pregnant or breastfeeding
Daily diuretic medication
Consumption of other strong medicines within 24 hours (Ayahuasca, San Pedro, Mushrooms)
Recent Covid Vaccine (4-week exclusion)
Reached 70th birthday
Fasting for longer than 18 hours
SUBSTANCE GUIDELINE LIST: The following substances should be abstained before and after a Kambo session. Please confirm your understanding that you AGREE to the abstinence period by checking the box next to each substance. *
Alcohol (high doses): 48 hours before/ 7 days after
Alcohol (low doses): 12 hours before/ 24 hours after
Amphetamines (Adderall, Ritalin): 7 days before/ 7 days after
Anti-convulsants: must discuss with facilitator
Anti-Psychotics: Contraindicated
Ayahuasca & Analogues: 24 hours before/ 24 hours after
Benzodiazepines (Valium, Diazepam): 18 hours before/ 8 hours after
Beta Blockers: Do not take the morning of your session/ 8 hours after
Blood thinners: Do not take the morning of your session/ 8 hours after
Botox: 7 days before/ 7 days after
Cannabis: 12 hours before/ 24 hours after
Cocaine: 3 days before/ 5 days after
Crack Cocaine: 7 days before/ 7 days after
Ecstacy (MDMA): 7 days before/ 7 days after
Fentanyl: Contraindicated
Heroin: 14 days before/ 14 days after
Meth Amphetamine: 30 days before/ 30 days after
Morphine/Oxycodone: 5 days before/ 5 days after
LSD: 48 hours before/ 72 hours after
Psilocybin: 24 hours before/ 24 hours after
Tramadol: 48 hours before/ 24 hours after
Vasoconstrictors (Triptans): 3 days before/ 12 hours after
Covid Vaccine: 30 days before/ 7 days after
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

Please list any and all medications and/or supplements you are currently taking: *
INFORMED CONSENT: *
By Checking this box, you AGREE to disclose any and all relevant medical history, medications, or health conditions that could affect your session
EMERGENCY MEDICAL TREATMENT:
By checking this box, you AGREE to allow your practtioner to seek emergency medical support and/or treatment for you if necessary, and you AGREE to cover any and all related costs
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*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
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
Being on a no-salt diet (ayahuasca diet)
Ehlers Danlos or Marfan syndrome
Medication for low blood pressure
History of stroke, brain hemorrhage, or blood clots
Lack the mental capacity to consent
Serious mental health issues (excluding depression, PTSD, and axiety)
Undergoing chemotherapy, radiotherapy, or immunotherapy (6 weeks exclusion)
Use of immune-supressants for organ transplant
Addison's disease
Current or severe epilepsy
Recovering from major surgery
Under 18 years old
Pregnant or breastfeeding
Daily diuretic medication
Consumption of other strong medicines within 24 hours (Ayahuasca, San Pedro, Mushrooms)
Recent Covid Vaccine (4-week exclusion)
Reached 70th birthday
Fasting for longer than 18 hours
SUBSTANCE GUIDELINE LIST: The following substances should be abstained before and after a Kambo session. Please confirm your understanding that you AGREE to the abstinence period by checking the box next to each substance. *
Alcohol (high doses): 48 hours before/ 7 days after
Alcohol (low doses): 12 hours before/ 24 hours after
Amphetamines (Adderall, Ritalin): 7 days before/ 7 days after
Anti-convulsants: must discuss with facilitator
Anti-Psychotics: Contraindicated
Ayahuasca & Analogues: 24 hours before/ 24 hours after
Benzodiazepines (Valium, Diazepam): 18 hours before/ 8 hours after
Beta Blockers: Do not take the morning of your session/ 8 hours after
Blood thinners: Do not take the morning of your session/ 8 hours after
Botox: 7 days before/ 7 days after
Cannabis: 12 hours before/ 24 hours after
Cocaine: 3 days before/ 5 days after
Crack Cocaine: 7 days before/ 7 days after
Ecstacy (MDMA): 7 days before/ 7 days after
Fentanyl: Contraindicated
Heroin: 14 days before/ 14 days after
Meth Amphetamine: 30 days before/ 30 days after
Morphine/Oxycodone: 5 days before/ 5 days after
LSD: 48 hours before/ 72 hours after
Psilocybin: 24 hours before/ 24 hours after
Tramadol: 48 hours before/ 24 hours after
Vasoconstrictors (Triptans): 3 days before/ 12 hours after
Covid Vaccine: 30 days before/ 7 days after
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

Please list any and all medications and/or supplements you are currently taking: *
INFORMED CONSENT: *
By Checking this box, you AGREE to disclose any and all relevant medical history, medications, or health conditions that could affect your session
EMERGENCY MEDICAL TREATMENT:
By checking this box, you AGREE to allow your practtioner to seek emergency medical support and/or treatment for you if necessary, and you AGREE to cover any and all related costs
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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