Kambo Cleanse Questionaire

Please fill out this form so that we can make sure you are ready to sit with Kambo Medicine.

Name *

First

Last

Email *

Phone

Date of Birth

Is this your first time working with Kambo?

Yes
No

Have you ever had, or currently have, any heart issues, blood pressure issues, blood clots or epilipsy?

Yes
No

Have you ever been diagnosed with a serious psychiatric illness? (excluding PTSD, anxiety, depression)?

Yes
No

Have you ever had an organ transplant?

Yes
No

Have you ever experienced chest pains, dizziness or fainting?

Yes
No

Have you had surgery (including dental) in the past 6-months?

Yes
No

Please list any medications and/or supplements you are taking:

Have you worked with Bufo alvarius toad and/or 5-MEO-DMT molecule in the last 5 weeks?

Yes
No

Are you pregnant or breastfeeding?

Please share any other medical conditions or issues: (all information is confidential)

Kambo can be a are a powerful cleansing catalyst to your healing journey. Soultech will provide best-in-class experience, resources and support. It is crucial to take ownership for your own actions and healing journey. The following agreements demonstrate that you are ready to actively engage in your Kambo experience.

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Confirm you are over 18 years old

Yes

I declare that I understand that Kambo is not medical treatment or a substitute for medical treatment.

Yes

I declare that I will adhere to all instructions given by the Soultech Sanctum team. Failure to do so renders me fully responsible for the outcome.

Yes

I give my full consent for the application of Kambo. I understand that this will involve superficial burning of the skin.

Yes

I declare that I do not have any serious psychiatric or physical illnesses that I have not disclosed.

Yes

I declare that I understand that the Soultech Sanctum team are not to be held accountable or responsible for any effects that could potentially occur in response to this treatment.

Yes

I declare that I understand that no claims have been made that Kambo can treat or cure any disease or illness.

Yes

I declare that I undertake this treatment at my own risk and responsibility.

Yes

Anything else we should know?

DISCLAIMER: The information provided on this webpage is intended for informational purposes only and does not constitute medical advice. Kambo is a traditional medicine that involves the secretion of the Phyllomedusa bicolor frog, and its use can have intense physical and psychological effects. This content is not intended to diagnose, treat, cure, or prevent any disease. Always consult with a qualified healthcare professional before undertaking any form of treatment, including kambo, particularly if you have pre-existing health conditions, are pregnant, or are on medication. Kambo has not been evaluated or approved by the U.S. Food and Drug Administration (FDA) or other regulatory bodies, and its use carries risks. It should only be administered by trained practitioners in a safe environment. We do not guarantee any specific outcome or benefit from the information provided here or from the practice of kambo, and we do not assume liability for any adverse reactions or health complications that may arise. Please carefully consider all aspects of this treatment, including potential health risks, ethical concerns, and cultural sensitivity, before participating in a kambo session. For additional guidance and support, consult with medical professionals and experienced practitioners.