Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Medications *

Are you now, or have you recently taken any psychotropic medications or substances including but not limited to SSRI, SNRI, NDRI, or MAOIs, or any medications for depression, anxiety, ADHD, or similar conditions?

Yes

No

Do you have any heart conditions? *

Yes

No

Do you have high blood pressure? *

Yes

No

Do you have any major health issues? *

Yes

No

Do you have any of the conditions listed on the Triangle Kambo Contraindications page? *

Yes

No

Do you have previous experience with Kambo and/or plant medicine? *

Yes

No

Disclaimer *

Kambo is a traditional Amazonian cleansing practice, not a medical treatment. While many people experience profound benefits, the use of Kambo has not been evaluated or approved by the FDA, and no medical claims are made regarding its ability to diagnose, treat, or cure any disease. Participation in a Kambo session is voluntary and undertaken at your own risk. It is essential that you disclose all relevant health conditions, medications, and medical history to your facilitator prior to your session. Certain conditions, including but not limited to heart problems, serious mental health disorders, low blood pressure, or pregnancy, may make Kambo unsafe. Triangle Kambo and its facilitators are not licensed medical professionals and do not provide medical advice. Kambo is a complementary spiritual and traditional healing practice and should not replace professional medical care. If you have any health concerns, consult with a qualified healthcare provider before participating. By choosing to sit with Kambo, you acknowledge that you have been informed of the potential risks, understand the contraindications, and accept full responsibility for your participation.

I understand and agree