Book Kambo Session | The Healing Hub

Personal Details

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

Preferred Date *

Preferred Time

Emergency Contact

Emergency Contact Name *

Emergency Contact Phone *

Kambo Health Screening & Contraindications

Please complete this full screening carefully. This information is essential for your safety and will be kept strictly confidential.

Do you currently have or have you ever had any of the following?

Heart conditions or cardiovascular problems

History of stroke or brain haemorrhage

Blood clots or bleeding disorders

Very low blood pressure

Epilepsy or seizure disorders

Organ transplant recipient

Currently pregnant or breastfeeding

Serious mental health conditions (e.g., psychosis, schizophrenia)

Addison's disease or adrenal insufficiency

Serious liver or kidney conditions

Pancreatitis (current or history)

Recent surgery (within the last 6 months)

Currently undergoing chemotherapy or immunotherapy

Have done water fasting or extreme diets in the last 7 days

Taking medications or using recreational drugs (details required below)

Have had previous adverse reactions to Kambo

Please list any current medications, supplements, or additional health information:

1) Please list any health conditions you may have *

2) Please list any previously diagnosed or current mental health issues *

3) How would you describe your current mental state? *

Please list all medications you are taking, including any drug use *

Recreational substances used recently (optional, for pre/post timing guidance):

Alcohol

Cannabis

Stimulants (e.g. cocaine, amphetamine/MDMA)

Opioids

Benzodiazepines

Other / unsure

Have you had Kambo before? *

Yes

No

6) What is your reason / intention for receiving Kambo? *

Kambo Standardised Information Sheet

Please read this carefully. This is the main information and disclaimer that you are digitally signing.

Scope: Kambo is a traditional cleansing practice and complementary therapy. It is not a medical treatment, and outcomes are not guaranteed.

Physical and emotional effects: Kambo can produce intense physical reactions and may bring unprocessed emotions to the surface. A short healing/integration process after treatment is possible.

Key contraindications (not exhaustive): heart conditions or significant cardiovascular issues, stroke/brain haemorrhage history, blood clots/bleeding disorders, epilepsy or seizure disorders, organ transplant, pregnancy or breastfeeding, Addison’s disease, serious liver/kidney/pancreatic conditions, active chemotherapy/immunotherapy, and severe mental health disorders (including psychosis, schizophrenia, schizoaffective disorder, unmanaged bipolar, and severe personality disorders).

Medication and substance safety: You must disclose all medications, supplements, and recreational substance use. Certain substances and medication dependencies may make treatment unsafe or require postponement.

Food and hydration: Food should be avoided for at least 8 hours pre-treatment. On treatment day, only small amounts of water should be consumed if needed, following practitioner guidance.

Post-care: Avoid other medicines/therapies for at least 48 hours after treatment and avoid alcohol/recreational drugs for at least 5 days after treatment unless medically required and approved by a qualified clinician.

Medical responsibility: If you are unsure about suitability, seek advice from an appropriate medical professional before treatment. You are responsible for providing complete and accurate health information.

Liability and consent: By signing, you confirm that you understand the information above, that KPA practitioners are not medical doctors, and that you voluntarily accept treatment-related risks and responsibilities.

I confirm I have read and understood the Kambo Standardised Information Sheet above. *

KPA Disclaimer & Digital Signature

I understand that KPA practitioners are not medical doctors and do not diagnose disease, prescribe pharmaceuticals, or replace appropriate medical/psychological care.

I confirm that any complementary therapy I receive is not a substitute for diagnosis or treatment by a qualified medical practitioner.

I confirm that all details provided are true and accurate, and I understand that Kambo outcomes cannot be guaranteed.

I release the KPA and KPA practitioner from liability resulting from use of equipment, materials, preparations, remedies, or treatments, and I assume full responsibility for risks relating to this treatment.

I understand and agree to the KPA disclaimer terms above. *

I understand I am voluntarily accepting all treatment-related risks and responsibilities. *

Digital Signature *

Sign with your mouse or finger.

Print Name *

Date

Additional Information

Is there anything else you'd like us to know?

I confirm that the information provided above is accurate and complete. I understand that Kambo is a powerful healing practice and I take responsibility for disclosing all relevant health information. *