Kambo Waiver
I certify that I am seeking the consultation and services of Andrew Snope and Jordan Ryan of Integrative Wellness Solutions LLC, which I fully understand are not medical diagnoses or treatments or substitutes for medical diagnoses or treatments. I accept full responsibility for my health and voluntarily complete this Acknowledgment and Waiver of Liability. I am of sound mind and am able to make the decision to have Kambo administered to me. I certify that I MUST disclose any and all allergies, surgeries, ailments, medications, addictions, health conditions (both past and present). If I do answer “yes” to anything on this list, I understand that it doesn’t automatically disqualify me as further information may be needed to safely receive Kambo.
I understand that I must disclose if I have had an organ removed/transplant or if I was born without an organ. I must disclose if I have had any type of surgery to assist me in losing weight. If I have been prescribed an inhaler, I MUST have it in my possession and available for the practitioner to use if needed. I understand that I must disclose if I am diabetic and have a pump. This does not disqualify me. I understand that if I have any skin condition, that the treatment can amplify the symptoms as it supports the body with healing, this included if I have a history of cold sores or have been diagnosed with herpes. I must disclose if I have taken ketamine or any synthetic drugs within 2 weeks of ceremony (including MDMA, GHB, amphetamines, opiates, etc). Neither of these things inherently disqualify me for kambo, as more information is needed. I understand that I should continue to see any medical doctors I am currently under the care of and that any prescription medication should not be altered without consulting the doctor who recommended it.
Please respond to the following: