New Client Form

. 

Your information is safe on this website and will never be shared.

Please complete the form below with as much information as possible making sure your email address is correct as I will be sending you more information regarding your treatment. 

All information given to me is treated in the strictest confidence.

IMPORTANT! Please take time to read through the contraindications below. Kambo is not for everybody and excluded for those with the following health conditions for safety purposes:

  • Serious Heart Problems (if you are unsure please call to discuss)…
  • Stroke…
  • On medication for low blood pressure…
  • Aneurysms or blood clots…
  • Anyone lacking the mental capacity to make the decision to take Kambo…
  • Serious mental health problems… 
  • Undergoing chemotherapy and for up to 4 weeks afterwards…
  • On immune-suppressants for an organ transplant…
  • Women who are pregnant or maybe so…
  • Women who are breastfeeding a child under 6 months old…
  • Addison’s disease…
  • If you have taken bufo alvarius very recently…
  • People recovering from surgery before 12 weeks…

Other points to note:

  • If you are asthmatic please make sure to bring your inhaler.
  • If you have diabetes, please contact me to discuss treatment in advance.
  • If you are menstruating be aware that Kambo contains powerful vasodilators, therefore, may increase the flow for 24-36 hours following treatment.
  • If you have ever or are currently suffering from a mental health condition (excluding depression) please contact me to discuss, regardless of whether or not you are taking medication.
  • Also please contact me beforehand if you are taking any anti-depressants, medications or supplements to let me know what they are.
  • Long-term juice/ water fasters or high-intensity athletes please let me know.
  • If you are having a liver or parasite cleanse please let me know before, I serve Kambo 5 days after this treatment has ended. 

    Although highly unlikely, Kambo can be dangerous. I will do a screening before every appointment to minimize the risk. I make all my clients aware of a condition called Boerhaave Syndrome: Spontaneous Oesophageal Rupture resulting from sudden increased intra-oesophageal pressure. Again extremely rare, you can read more about it  HERE 
Select the name of your Practitioner. If they are not listed, contact them directly.
Some questions are gender-related
I serve a light vegan meal after your treatment.
If none please say NO
Please list all medication/s. If not taking any say none.
If you have no health conditions please say none.
Stomach ulcers, Any previous Oesophagus/Esophagus bleeding or rupture
Please include excessive drinking
Please include any investigations
This might not affect your eligibility to have Kambo but is useful information to determine how Kambo will be applied to you.
Disclaimer: I understand that Kambo Tree Coalition practitioners are not medical doctors or other medical practitioners. I understand that Kambo Tree Kambo Coalition practitioners do not diagnose disease, offer health advice, treat physical or mental health issues, or prescribe medicine or pharmaceuticals. I understand that any complementary therapy treatment which I receive is not a substitute for a medical or psychological diagnosis or treatment by a qualified medical practitioner. I understand that it is recommended that I see such a practitioner for any physical or psychological problem I have now or in the future. I am aware of the risk of Boerhaave Syndrome - Oesophagus/Esophagus rupture and other risks associated with Kambo. I further confirm that all the details provided are true and accurate. I hereby release my chosen Kambo Tree Coalition from all liability resulting from using equipment, materials, preparations, remedies, or treatments and assume full responsibility for all risks regarding this treatment. I confirm that I am of lawful age and fully understand the contents of this document.