Name *

First Name

Last Name

Phone

(###)

###

####

Have you received Kambo before? *

Yes

No

Have you taken iboga or Ibogine within the last 3 months? *

Yes

No

Have you received Bufo or 5Meo-Dmt within the last 3 months? *

Yes

No

Are you able to abstain from alcohol and drugs for at least 3 days before and 3 days after session? *

Yes

No

Are you currently pregnant or breastfeeding? *

Yes

No

Do you currently have or have a history of any of the following? Check all that apply to you *

Heart problems including severe heart attack or heart disease

An implantable cardiac device

Stroke or aneurysm

Blood clots

Bleeding in the brain

Severe head injury

Epilepsy or history of seizures

Problems with the liver and/or kidney

Active hernia

Serve psychological conditions (not including anxiety or depression)

Medicated low blood pressure

History of bulimia or disordered eating

Drug or alcohol addiction

Asthma

Diabetes

Autoimmune conditions

Lyme disease

History of Mania, Psychosis or related psychological episodes

None of the above

Other

Preparation *

Pleaser fast for 12 hours before your session and follow the recommended diet protocols. Fasting for more than 18 hours + colonics, enemas, saunas and sweat lodges should be avoided for 2 days before and the day after receiving Kambo.

I agree

Medical Condition Acknowledgment: *

I affirm that I have disclosed all my known medical conditions and medications to the Kambo practitioner. I understand that Kambo treatments may not be suitable for individuals with certain health issues such as cardiovascular problems, neurological disorders, pregnancy, or other significant medical conditions.

I agree

Release of Liability *

I hereby release, waive, and discharge the Kambo practitioner(s) and associated personnel from any and all liabilities arising from my participation in the treatment, including but not limited to physical, mental or emotional discomfort. By consenting to this release, you waive any rights to claim compensation for injury, loss or damage that may occur.

I agree

Acknowledgment and Consent *

I acknowledge that I have read and understood the nature of the Kambo treatment, including potential risks. By agreeing to this informed consent, you accept full responsibility for your voluntary choice to participate in the Kambo experience. the treatment willingly and voluntarily.

I agree

Please confirm your contribution through Zelle or Venmo *

Zelle: lila@lilalunaa.com Venmo: @lilazimmerman

I agree