Kambo Consent Form

Your Name

Your Email

Your Date of Birth

Occupation

Have you worked with Kambo before

yesno

What supplements, medications are you currently taking?

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

I agree to the following:

• I apply for and consent to a session of Kambo therapy.

• I understand that the general process and results of Kambo therapy can vary for each individual and that specific results cannot be guaranteed.

• I have read and understood the list of: Precautions for Safely Taking Kambo

• I affirm that I have or will notify my practitioner of all known medical conditions and injuries before my first Kambo therapy session.

• I agree to inform the practitioner of any changes in my health and/or medical condition. I understand that there shall be no liability on the practitioner’s part should I neglect to do so.

• I understand that the services offered are not a substitute for traditional medical care.

• I understand that the practitioner does not treat, prescribe for, or diagnose any illness, disease, or any other physical or mental disorder, injury, or condition. Nothing said or done by the practitioner should be construed to be such.

• I further understand that the practitioner is not attempting to practice medicine, psychology, or any other profession requiring a license.

• I agree to pay for any appointments that I miss or do not cancel with 48 hours advance notice.

By signing below and submitting this form I certify that I have read, understood, and accepted this agreement and that I have read and understood the Precautions for Safely Taking Kambo