KAMBÔ SAGRADO

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Type of session you are interested in *

Single Session

Deep Cleanse (3 sessions)

Kambô / Trauma Release Breath Work

Not sure

Kambô Munich

Please select all that are applicable. *

Heart disease or heart conditions

Blood clots

Chemotherapy or radiation

Stroke

Organ, stem cell or other implants

Low or High blood pressure

Mental health conditions (excluding depression and anxiety)

Artificial devices in the body such as stent or pace maker etc.

Epilepsy

Aneurism

Active ulcers

Kidney, Liver or Addisons disease

Recovering from a major procedure

Asthma or respiratory issues

Diabetes

Pregnant or breastfeeding

COVID-19

Not applicable

Have you experienced other alternative natural medicines? *

Ayahuasca

Iboga

Mushrooms

Sananga

Rapé

None

I declare that all the information I provided in this questionnaire regarding my past and current medical conditions and use of medication is true and correct. I understand the possible treatment symptoms include: fainting, dizziness, facial swelling, nausea, vomiting, defecating, excessive sweating and headaches. *

Agree

Disagree

I understand that cancellations less than 24 hours before the appointment are non-refundable. If I am unable to attend I can transfer the appointment to another date. *

Agree