KAMBÔ CONSULTATION FORM
Welcome, dear Kambô seeker!
Please complete this form in a transparent and clear manner. 

In order to evaluate your situation and establish if you are suitable to receive Kambô I need as much detail and insight as possible. There is lots of information on my website and my instagram page, I invite you to read through that as well. 

There is no judgement here, please be yourself. All information is strictly confidential.

Once I've read the form I will reply to your email, if you don't see anything in a couple days, please check the junk folder :)

Thank you!
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Email *
FIRST AND LAST NAME + Instagram Handle (if 
we have communicated over there)                                                
 *
DATE OF BIRTH *
CONTACT NUMBER (I will only message if it appears my email has gone to junk folder) *
HAVE YOU RECEIVED KAMBÔ BEFORE? 
IF SO, HOW WAS YOUR EXPERIENCE?
 *
TELL ME A LITTLE ABOUT YOURSELF - WHAT DO YOU DO FOR A LIVING, HOW ARE YOU FEELING AT THE MOMENT?  

 *
Is there anything going on in your life (work/personal/health) that is affecting your physical, mental, or energetic state of being?
ARE YOU CURRENTLY TAKING ANY PRESCRIBED MEDICATION? THIS INCLUDES TABLETS, INHALERS, CREAMS, WEIGHT LOSS INJECTIONS etc 

IF SO, PLEASE LIST WHAT KIND, DOSAGE AND WHAT FOR:
ARE YOU CURRENTLY TAKING ANY NATURAL REMEDIES OR SUPPLEMENTS?  

IF SO, PLEASE LIST WHAT KIND:
WHAT IS YOUR DIET LIKE? DO YOU AVOID ANY FOODS? DO YOU HAVE ANY DIGESTIVE ISSUES?
ANY MAJOR CURRENT OR PAST HEALTH ISSUES, HOSPITALISATIONS, SURGERIES?
HOW ARE YOUR STRESS LEVELS
DO YOU SMOKE OR VAPE?
DO ANY OF THESE APPLY TO YOU (very important to establish if special precautions are needed) :
Have you received any vaccines in the last 6 months?
If applicable - are you on any form of contraception, any past pregnancies or terminations? 

How is your monthly cycle?
What do you hope to gain from your Kambô ceremony and working with this medicine? 

Do you understand the process of the ceremony? 
Please add anything you feel is important, needs clarification, or that you are unsure of.
"I declare that all the information I provided in this questionnaire regarding my past and current medical conditions and use of medication is true and correct. I understand that withholding information, particularly a contraindicated condition or medication, may pose a serious safety risk.

I understand the possible treatment symptoms include: nausea, vomiting, facial swelling, excessive sweating and headaches, dizziness and very rarely fainting."

Kambô is a traditional Indigenous medicine and none of this information should be considered a promise of benefits, a claim of cures, a legal warranty or a guarantee of results to be achieved. You should consult with a healthcare professional before altering or discontinuing any current medications, treatment or care, starting any diet, exercise or supplementation program, or if you have or suspect you might have a health problem.
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