Giving Tree Medicine

Kambo Intake Form

Full name

Phone

Emergency Contact and Phone Number

How did you find out about my Kambo Ceremony?

Whom may I thank for sending you my way?

Have you ever experienced Kambo before? If so, briefly describe your experience.

What are your intentions for seeking Kambo therapy?

Please list all medications and supplements that you are currently taking as well as dosage for each.

Things that should be avoided before Kambo

Please read carefully. Mixing Kambo with any of the following could be extremely dangerous:

Immune suppressants for auto immune disorders.
Slimming or sleeping supplements (including melatonin).
Alcohol or drugs 24 hours before and after.
Do not fast longer than 18 hours, 7 days before or after Kambo. This includes juice fast. Clients should have a normal eating pattern leading up to Kambo including salt.
Sweat lodges, Colonics, enemas, liver flushes or any water based detox should be avoided within 3 days either side of taking Kambo.

By checking "I Agree” you are agreeing that you have read the above regarding what should be avoided before Kambo and that you understand the dangers involved should you choose to neglect the above.

I agree.

Kambo does not generally have unintended adverse effects when administered by a properly trained practitioner and when clients have disclosed any underlying health conditions.

You should absolutely not participate in a Kambo treatment if any of the following apply:

Have serious heart problems
Are on a no-salt diet (avahuasca diet)
Have Elhers Danlos Syndrome
Have Marfans Syndrome
Are on medication for low blood pressure
Have had a stroke
Have had a brain hemorrhage
Have an aneurism or blood clots
Lack the mental capacity to make the decision to take Kambo
Have serious mental health problems excluding depression, PTSD and anxiety
Are undergoing chemotherapy, radiotherapy or for 6 weeks afterwards
Take immune-suppressants for organ transplant
Have Addison's Disease
Have current and severe Epilepsy
Are recovering from a major surgical procedure
Are under 18 years old
Have undergone a Bufo ceremony in the past 6 weeks
Are pregnant or might be
Taking a daily diuretic. If you are on a medication that is also a diuretic but is not required to be taken daily, check with your practitioner to see if Kambo is safe for you.
Have consumed other strong medicines (eg.
San Pedro, Ayahauaca, Mushrooms) within 24 hours of wanting to receive Kambo
Person has reached their 70th birthday
Have consumed large amounts of water prior to arriving for Kambo
Have been fasting longer than 18 hours.
Have received the Covid Vaccine in the last 4 weeks

By checking "I Agree", you are agreeing that you have read the above regarding contraindications of Kambo and that you understand the dangers involved, should you choose to neglect the above.

I agree.

Substance Guideline List

Please review the below list of substances that should be abstained from before and after taking Kambo. By checking the "I Agree" box to each substance you are confirming that you understand the time period to abstain from that particular substance both pre and post Kambo and that you understand the dangers involved should you choose to neglect the information provided to you regarding the substance guideline.

SUBSTANCE

BEFORE KAMBO MINIMUM ABSTINENCE PERIOD / POST KAMBO MINIMUM ABSTINENCE PERIOD

Alcohol High Doses

48 HOURS / 7 DAYS

Alcohol Low Doses

12 HOURS / 24 HOURS

Amphetamines Including Adderall and Ritalin

7 DAYS / 7 DAYS

Anti-Depressants and Anxiety Medication including Duloxetine/Cymbalta

Do not take morning of for morning sessions / 2 hours

Anti-Convulsants - must discuss with facilitator if on an anticonvulsant medication

Anti-Epileptics - CONTRAINDICATED, DISCUSS WITH FACILITATOR

Anti-Psychotics - CONTRAINDICATED, DISCUSS WITH FACILITATOR

Ayahuasca & Analogues e.g. contingent that client is not on a no-salt diet. 24 hours / 24 hours

Benzodiazepines e.g. Valium, Diazepam

18 hours / 8 hours

Beta Blockers

Do not take morning of treatment / 8 Hours

Blood Thinners

Do not take morning of if morning session/ 8 Hours

Botox

7 days / 7 days

Bufo, 5-meo DMT

6 weeks / 24 hours

Cannabis

12hrs / 24hrs

Cocaine

3 days / 5 days

Coca Leaf

12hrs / 24hrs

Codeine

24 Hours / 24 Hours

Crack Cocaine

7 days / 7 days

Ecstasy (MDMA) Molly or any other MD**

7 Days / 7 Days

Fentanyl - CONTRAINDICATED, DISCUSS WITH FACILITATOR

GHB

7 Days / 7 Days

Heroin (recreational)

14 Days / 14 Days

Heroin Substitutes - Methadone, Buprenorphine, Naltrexone CONTRAINDICATED, DISCUSS WITH FACILITATOR

High Blood Pressure Medication

Do not take morning of if morning session / 8 Hours

Iboga

90 days / 24 Hours

Ibogaine

10 days / 24 Hours

Ketamine

3 Days / 3 Days

Krokodil (Desomorphine) - CONTRAINDICATED, DISCUSS WITH FACILITATOR

LSD

48 Hours / 72 Hours

Meth Amphetamine

30 Days / 30 Days

Morphine/Oxycodone

5 Days / 5 Days

Nitrous Oxide

12 Hours / 12 Hours

Peyote San Pedro (Mescaline)

24 hours / 24 hours

Pink (U-47700) - CONTRAINDICATED, DISCUSS WITH FACILITATOR

Psilocybin

24 hours / 24 hours

Research Chemicals - SPICE, Bath Salts, Mephedrone, Synthetic cannabinoids + more

For limited recreational usage, 30 days before treatment. Habitual use is CONTRAINDICATED / 30 Days

Tramadol

48 Hours / 24 Hours

Vasoconstrictors (Triptans)

3 Days / 12 Hours

2CB

48 Hours / 3 Days

Covid Vaccine or Booster

30 days / 7 days

AGREEMENT TO FOLLOW DIRECTIONS

I agree to follow any oral instructions or directions given by the practitioners.

Printed Name

Age

Signature

Date