Client Care Form Name * First Name Last Name Date of Birth MM DD YYYY Email * Phone * (###) ### #### Emergency Contact Name First Name Last Name Emergency Contact Phone (###) ### #### Health Questions: Serious Heart Problems * Yes No Medicated Low Blood Pressure Yes No Abnormally high or low blood pressure Yes No Stroke, Brain Hemorrhage, Aneurism, Blood Cloths Yes No Lack the mental capacity to make the decision to take Kambo Yes No Serious mental health problems Yes No Undergoing or have been undergoing chemotherapy or radiotherapy Yes No Taking immune-suppressants for organ transplant Yes No Addison’s Disease Yes No Current and Severe Epilepsy Yes No Recovering from major surgical procedure Yes No Take immune-suppressants for autoimmune disorder Yes No Serious eating disorder e.g. Bulimia or Anorexia Yes No Active Drug Addiction Option One Option Two Take regular high doses of slimming, serotonin and/or sleeping supplements Yes No Fasted for more than a few days before Kambo Yes No Liver or Kidney problems Yes No Asthma Yes No Diabetes Yes No Regularly consume diuretic medication or sports drinks Option One Option Two Females ONLY: Are you pregnant or may be so, or are breastfeeding a child under 6 months old Yes No Females ONLY: Undergoing fertility treatment Yes No Females ONLY: First day of your last moon cycle: Please list current Medications / Supplements: Disclaimer I understand that Kambo International practitioners are not medial doctors, now any other form of medical practitioner. I understand that Kambo International practitioners do not diagnose disease, offer health advise, treat physical or mental health issues, or prescribe medicine or pharmaceuticals. I understand that any complementary therapy treatment which 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 that I see such a practitioner for any physical or psychological problem I have now or in the future. I confirm that I have read and understand the list of contraindications provided, and agree that I do not have any conditions that would contraindicate me from taking kambo. I further confirm that all the details provided are true and accurate. I hereby release Steve Dumain from all liability resulting from the use of equipment, materials, preparations, remedies or treatments and assume full responsibility for all risks regarding this treatment. * By checking this box I confirm that I am of lawful age and fully understand the contents of this document. Thank you!
