Kambo Spirit Berlin

Please fill out this form and be transparent with your medical history.

This will enable me to create a better session and make sure you are safe at all times!

Thank you 🐸 ❤️

Name *

E-mail Address *

Phone *

Date of Birth *

Day

Month

Year

What Are You Interested In? *Single SessionMultiple SessionsFurther Information

How did you hear about Kambo? *

When was the last time you received Kambo? *

Are you currently having any health issues? *

Have you had any health issues in the past? *

List any and all medications or supplements you are currently taking? *

Please share anything else which you think might be relevant?

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. *AgreeDisagree

| 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