Loading...

Kambo Waiver and Contraindications Agreement 


I. Practitioner Information

Nicole Kemp, of Nicole Renee Healing

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. 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 outcomes. The practitioner and the organization they are affiliated with 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.

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. This waiver is legally binding and should be adjusted to reflect local laws and regulations.
AdultMinor(s)
1 Minor2 Minors3 Minors4 Minors5 MinorsMore Minors6 Minors7 Minors8 Minors9 Minors10 Minors
Continue

IV. 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:

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 anxiety)
Undergoing chemotherapy, radiotherapy, or immunotherapy (6 weeks exclusion)
Use of immune-suppressants for organ transplant
Addison's Disease
Current or severe epilepsy
Recovering from major surgery
Under 18 years old
Pregnancy 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

V. Substance Guideline List

The following substances should be abstained from before and after a Kambo session. Please confirm your agreement to each abstinence period (before Kambo / after Kambo):

Alcohol (High Doses): 48 Hours / 7 Days
Alcohol (Low Doses): 12 Hours / 24 Hours
Amphetamines (Adderall, Ritalin): 7 Days / 7 Days
Anti-Convulsants: Must discuss with facilitator
Anti-Psychotics: Contraindicated
Ayahuasca & Analogues: 24 Hours / 24 Hours
Benzodiazepines (Valium, Diazepam): 18 Hours / 8 Hours
Beta Blockers: Do not take morning of treatment / 8 Hours
Blood Thinners: Do not take morning of treatment / 8 Hours
Botox: 7 Days / 7 Days
Cannabis: 12 Hours / 24 Hours
Cocaine: 3 Days / 5 Days
Crack Cocaine: 7 Days / 7 Days
Ecstasy (MDMA): 7 Days / 7 Days
Fentanyl: Contraindicated
Heroin: 14 Days / 14 Days
Meth Amphetamine: 30 Days / 30 Days
Morphine/Oxycodone: 5 Days / 5 Days
LSD: 48 Hours / 72 Hours
Psilocybin: 24 Hours / 24 Hours
Tramadol: 48 Hours / 24 Hours
Vasoconstrictors (Triptans): 3 Days / 12 Hours
Covid Vaccine: 30 Days / 7 Days

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. This waiver is legally binding.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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*
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!