Consultation Intake Form

Required before receiving Kambo from me

I am currently not seeing clients or conducting clinics as I have transitioned-out of NYC & Henderson, NV and have yet to set-up shop elsewhere. Please check back for updates (posted this edit Tuesday, July 25, 2023)

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Please fill out the Kambo Consultation Intake Form for a prompt follow-up email to schedule a telephone conversation. Thank you!

Important: This is a CONFIDENTIAL questionnaire to help in assessing if Kambo is safe for you. Some health conditions and medications are contraindicated. By submitting this form you are acknowledging that all information is true and that you have not withheld or obfuscated anything vital. Failure to disclose vital health and / or medical history information can potentially result in serious safety issues.

If you have technical issues with the form, I can also email you a document to fill-out and return.

CONSULTATION / INTAKE FORM -

    What is your gender?
    MaleFemale

    What is your age?

    How many times have you taken Kambo or Sapo?
    01-33+

    List prescription medication(s) and / or any non-prescription, dietary supplements, diet aids, sleep aids, herbs, or recreational drugs that you currently take or have taken in the past 30 days. Please include any entheogens or sacramental substances / sacred medicines or sacred medicine ceremonies in which you've participated. (required)

    Do you have any current or previous health issues or concerns? Please explain. (required)

    Are you experiencing, or have you experienced any psychological health issues, e.g. schizophrenia, clinical severe depression, bipolar disorder, nervous break down, psychosis, PTSD, etc. (FYI: mild depression excluded) (required)

    Are you currently practicing, or have you practiced any form of extreme (restrictive) dieting, fasting, water fasting, cleansing (including colon hydrotherapy / colonics), 'Sweat Lodge / Inipi,' 'Vision Questing,' 'Sundance,' intensive physical activity (marathon running, hot yoga bootcamps, HiiT, etc.) in the last 2 weeks? Especially the 72 hours prior to your appt. Please give details and dates.

    What is your comfort level with purging / vomiting in front of others into a bucket? It goes with the territory...

    Have you received one of the COVID-19 "vaccines" i.e. one of the experimental, liability free, mRNA or DNA biotechnologies? And are you aware that current trials do not end until 2023 - and that long-term safety data is not yet available? If you have, please give the date of your last injection. (required)

    Are you aware of the rare, but most common injuries / dangers associated with Kambo? E.g. Anaphylaxis or allergic reaction, hyponatremia, fainting and injury from falling, esophageal rupture? You are now. These rare but possible incidences (among others) will be discussed on our intake call.
    Please confirm by typing "acknowledged" (required)

    What are your intentions in receiving Kambo? Try to be as specific as possible.

    DISCLAIMER -

    • Kambo & Rife / Resonant Frequency Therapy are not Medicines
    • IAKP & Rife / Resonant Frequency Therapy Practitioners are not Doctors nor any other Form of Medical Practitioners
    • IAKP & Rife / Resonant Frequency Therapy Practitioners do not Diagnose Disease, Offer Health Advice, Treat Physical or Mental Health Ailments or Prescribe Medication
    • Participants are Advised to do their own Research as to the Potential Benefits of Taking Kambo or Getting Rife / Resonant Frequency Therapy - None are Offered or Implied Here
    • KAMBO is a Indigenous, Ancestral Practice from the Amazon Rainforest - It is not a Medical Treatment
    • Rife / Resonant Frequency Therapy is not a Medical Treatment
    • Please Note that None of the Services Offered on this Website Constitute any Form of Medical Practice
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