Date Of Booking * Name * First Name Last Name Email Phone (###) ### #### Date of birth * MM DD YYYY Emergency Contact Name * First Name Last Name Emergency Contact Number * (###) ### #### Please take the time to read and understand this form carefully. Ensure that all questions are answered fully and accurately * Kambo has been known to assist with: Depression and anxiety PTSD and trauma recovery Fertility and hormonal balance Chronic pain relief Cancer support Increased mental clarity and emotional release Ceremony Details: Duration: 2–3 hours (longer for group ceremonies) Preparation to ensure comfort and set intentions 20–45 minutes of treatment Rest and integration time Process: Kambo is applied to small burns on the skin. A test dose is administered to determine the appropriate amount. Effects may include nausea, tingling, flushing, and purging (vomiting, tears, or bowel movements). These are normal detoxification responses and signal the release of toxins and imbalances. Preparation Guidelines to ensure the best experience: Bring 3 liters of water (avoid distilled water). Fast for 8 hours before arrival (no food or medication on the day of treatment). Do not fast leading up to the session; eat a meal the day before. Avoid saunas, colonics, or sweat lodges 48 hours before treatment. Bring a blanket and pillow for comfort. Contraindications Kambo is not suitable for individuals with the following conditions: Aneurysm, heart conditions, or organ transplants Brain-related issues or blood clots Active ulcers or recent surgeries (within 8 weeks) Pregnancy, breastfeeding (under 6 months), or within 21 days of childbirth Mental health conditions such as bipolar, schizophrenia, or psychosis Dependency on alcohol, opioids, or benzodiazepines Please disclose all health conditions, mental health issues, and medications in the form provided. Disclaimer: Blessed Kambo practitioners are not medical doctors and do not diagnose or treat medical or psychological conditions. Kambo is a complementary therapy and is not a substitute for professional medical advice. Terms & Conditions: Services may be refused without explanation. Contraindicated clients will not be treated. Cancellations within 48 hours are non-refundable. All packages must be used within 90 days of purchase. Sessions may be rearranged once with a minimum of 48 hours’ notice. Booking Policy Refunds: No refunds are provided; credit notes may be issued for cancellations with exceptional circumstances. Rearrangements: Allowed once with 48 hours’ notice. Exceptional Circumstances: A maximum of 50% refund or credit note may be issued. Start Your Journey Complete the form below: List any health conditions or medications. Share your mental health history. Specify your intention for this work. Kambo opens the door—it’s up to you to walk through it! 🐸 Do you agree to answer all questions fully and accurately as required? YES NO Do you have any contraindications to Kambo? * The following medical conditions are contraindications for Kambo treatment. If you have any of these conditions, you should not undergo Kambo: Aneurysm Active ulcers Alcohol dependence Addison’s Disease Brain injuries Blood clots Recent chemotherapy or chemo medications (within the last 6 weeks) Drug dependency, including opioids or benzodiazepines Prolonged diarrhea (lasting several days due to electrolyte imbalance) Gastric sleeve or band surgery Heart conditions (of any kind) Organ transplant recipients PTSD (only with advanced practitioners) Mental health conditions, including bipolar disorder, schizophrenia, psychosis, or personality disorders History of psychiatric conditions (must be disclosed prior to treatment) Low blood pressure (if medicated) Recent surgeries (within 8 weeks post-operation) Stroke Pregnancy Breastfeeding (under 6 months postpartum) Within 21 days of childbirth Under 18 years of age Severe asthma (requires prior assessment; inhaler mandatory) Diabetes (requires insulin, testing strips, and food during treatment) Recent Bufo use (within the last 8 weeks) Recent COVID vaccination (must wait at least 6 weeks post-vaccination) YES NO Please list any health conditions you may have... * * Please list any previous or current mental health issues... * Are you dealing with severe alcohol or drug addiction? * Have you experienced any psychotic episodes or significant mental breakdowns in the past? * Have you had Kambo before? * What is your reason/intention for receiving Kambo? * Please list any medications... * Have you received the COVID vaccine? * * Line Disclaimer * I understand that KPA-certified practitioners working with Blessed Kambo are not medical doctors or any other form of medical practitioners. I understand that KPA-certified 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 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 I consult a qualified medical practitioner for any physical or psychological problem I have now or in the future. I further confirm that all the details I provide are true and accurate. I understand that everyone’s Kambo experience is unique and that, while Kambo has produced outstanding results for many, Blessed Kambo and KPA practitioners cannot guarantee any specific outcomes. I understand that success rates, including those related to fertility, differ from person to person, and results may vary. I hereby release Blessed Kambo and the KPA from all liability resulting from the use of equipment, materials, preparations, remedies, or treatments, and I assume full responsibility for all risks associated with this treatment. No refunds will be given for cancellations made less than 48 hours before a session. In exceptional I agree to Disclaimer above Terms & Conditions * Blessed Kambo reserve the right to refuse services to anyone without explanation. If a client has any contraindication, Blessed Kambo reserve the right not to proceed with treatment. If a session is canceled less than 48 hours before the appointment, no refund will be issued unless under extreme circumstances. In such cases, a credit note may be provided at the discretion of Blessed Kambo. All clients are required to agree to and accept the disclaimer before proceeding with any treatment. Blessed Kambo and KPA-certified practitioners are not accountable for any specific results or effects you may or may not experience through Kambo treatments. For cancellations made more than 48 hours before the appointment, a 50% refund or a credit note for the value of the treatment will be issued. I agree to terms & conditions above Thank you!
