Kambo intake Form

Thank You for booking your Kambo Session

Please complete the below with as much detail as possible - even if you feel it is irrelevant. I will be in touch should I have any additional questions before your session

Korrin x

Name

Phone Number

Address

Tell me your purpose / intentions for Kambo...

Have you received Kambo before? If yes, tell me about your experience...

Please list any medical conditions you have or have a history of...

Please tell me of any current or previously diagnosed mental health conditions

Please list any medications or herbal remedies you are currently taking

Please declare any allergies

How would you describe your current mental state?

Do you currently have a good support network? friends, family etc

Tell me about your diet (Keto, Paleo, Vegetarian, Intermittent or longer term fasting etc)

I confirm I have read through the list of contrindications on the website and I have declared all medical information

Thank You for booking your Kambo Session

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