Intake Form

Kambo Intake Form

* Indicates required field

Name *

First

Last

Please share the reason you are seeking working with Kambo at this time of your life. *

Have you ever done Kambo before? If yes, please briefly describe your experience. *

Are you on any supplments or medications? If yes, please list them out. *

Have you done any other psychedelics in the past two-weeks including, 5MEO, DMT, or Ayahuasca? *

Yes No

Please list an emergency contact. Name and phone number. *

Email *

Phone Number *

Submit