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Kambo Consultation Form

Welcome to the first step toward a deeper, more purposeful life.

Why We Ask You to Complete This Form

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This ceremony is a sacred space for deep healing, and your safety is the foundation upon which that healing can unfold.
Before working with Kambo, we take time to understand each participant’s health, history, and needs so the medicine can meet you in the safest and most supportive way possible.

Kambo is a powerful natural medicine — it cleanses, releases, and awakens. Yet, as with any potent healing practice, it is not suitable for everyone. By completing this form honestly and fully, you allow us to:

  1. Ensure your safety — confirming there are no health conditions, medications, or circumstances that could place you at risk.

  2. Support your journey — so we can hold space for you in a way that is gentle, appropriate, and deeply respectful to your body, mind, and spirit.

Everything you share will remain private and confidential. Your openness here is an act of self-care, allowing the ceremony to be both transformative and safe.

Thank you for honouring this step — it ensures that when you enter the space, you can do so with trust, clarity, and readiness to receive Kambo’s wisdom.

Consultation form

Please fill out the form providing as much information as possible. 

If you have any questions or queries please let us know. 

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Please add an emergency contact, include name, phone number and address.

Do you have, or have you ever had, any of the following conditions? (Please tick all that apply)
Are you currently pregnant, breastfeeding, or trying to conceive?
yes
No
Have you had surgery in the last 8 weeks?
Yes
No
Have you experienced any illness, infection, or fever in the last 7 days?
Yes
No
Are you able to fast for 8 hours prior to the ceremony?
Yes
No
Single choice
Option 1
Option 2
Are you willing to follow the aftercare advice provided?
Yes
No
I understand that Kambo is a traditional Amazonian medicine and not a medical treatment, and that it carries potential risks.
Yes
No
I confirm that I have disclosed all relevant medical history, conditions, and medications.
Yes
No
I understand that all deposits are non-refundable.
Yes
No
I agree to participate voluntarily and take full responsibility for my decision.
Yes
No
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Date
Day
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