Jonalyn Blaha

Riding the bliss wave: The intersections of psychedelics and the body

Kambô Intake Form

Thank you so much for your interest in Kambo. In order to participate in a Kambo ceremony, you'll need to be approved as a good candidate. Once you've filled out and submitted this form, I will contact you via email within 24 hours. Once you are approved and the ceremony is scheduled, you will then be able to make a purchase on my website. 50% payment is due at the time of scheduling and 50% is due on or before the ceremony.

First and Last Name

Date of Birth

Today's Date

Group ceremonies are held on these dates. Choose the best date that works for you.

February 14, 15, 16, 2020 (FULL)

October 2020 TBA

Custom Dates (add below)

Tell me why you would like to work with kambo.

Please explain your selections above. Include how long you've had these symptoms and whether you're currently in treatment for the condition:

List all medications, supplements, herbs, and recreational drugs you've taken in the last month and the reason for taking them:

Contraindications:

Medications that are NOT compatible with Kambô include:

Parkinson’s medications
Heart disease medications
Epilepsy medications
Lyme's Disease medications (in some cases)
Blood pressure medications
Steroids (Arthritis + Rheumatism) medications
Corticosteroids medications
Infection (Diclofenac) medications
Sleeping pills/ medications
Varicose Vein medications
NSAID medications
Clove and other cleansing herbs

List of conditions that CANNOT be safely taken with Kambô:

Heart problems (of any and all kinds; this includes having a pacemaker
Stroke or Brain hemorrhage
Aneurysms or blood clots
Are recovering from a major surgical procedure with internal stitches
Schizophrenia or severe psychosis
Chemotherapy or radiotherapy (for at least 4-6 weeks afterwards)
Organ transplants (cannot be taken with immune suppressants)
Severe immune system disorders like MS or ALS
Pregnancy or breastfeeding a child under 6 months old
Addison’s disease
Hyper- and hypotension
Certain types of EDS
Epilepsy
Under 18 years of age

I've read the contraindications list. I do not take any medications on that list nor do I, to the best of my knowledge, have any of the conditions listed.

Waiver and Release of Liability

Upload File

Please click below to download the Waiver and Release of Liability form. Read through it carefully, initial and sign where indicated, and upload the file below.

By signing below, you acknowledge that you have filled out this form to the best of your ability and that you agree to the terms and conditions of the Waiver and Release of Liability Form.

I want to join the email list.

You will receive a response within 24 hours. Thank you!