In order for us to determine whether or not Kambo is safe and the right medicine for you, we need full medical disclosure.  Please fill out the medical form below completely, honestly and to the best of your knowledge truthful. Also, you need to understand that any failure to disclose all medications or diagnosed medical conditions could be to your detriment.

We can only determine your participation based on the information you provide in this form and you assume all responsibility for false or misleading information in the case of an emergency.