Name
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First Name
Last Name
What is your city and state?
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What type of offering/experience/session are you interested in?
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Private Kambo 'Warrior Cleanse' Series (1 on 1, 3 separate days)
Couples/Friends Kambo 'Warrior Cleanse' Series (2 people, 3 separate days)
Virtual Support Sessions: Prep, Integration or Deep Dive
Sananga Sound Dojo + Cacao Ceremony
other medicines
retreats
What are some areas of your life that you feel blocked in or would like to improve?
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For example, career, wellness, motivation, clarity etc. Please explain.
Is any of this applicable to you?
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If so, please be 100% transparent and click all that applies to you.
Heart disease, heart conditions or bypass
Low or high blood pressure
Don't know blood pressure
Asthma or breathing problems
Covid
Covid Vaccine
Diabetes
Blood clots
Recovering from a major procedure
Kidney, Liver or Addison’s Disease
Epilepsy
Chemotherapy or radiation within 8 weeks
Varicose veins
Artificial devices in body such as: stent, brain devices, etc.
Organ, stem cell or breast implants
Stroke, aneurysm or bleeding of the brain
Mental health conditions (discuss with practitioner)
Recent scorpion bite
Advanced stage Lyme’s Disease
Fasting or at the end of a fast or detox
Drugs within 3 weeks of intended ceremony
Recently taken Iboga or Bufo
Drink distilled water
Certain medications and herbs (REVIEW CONTRAINDICATIONS)
History of bulimia
Recent botox (within 10 days)
Not applicable to me
Gender reassignment
Please select all that apply re: Covid
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If so, please be 100% transparent and click all that applies to you.
Personal current exposure within the past 1-3 months
Personal exposure within the past 3-6 months
Personal exposure within the past 6-9 months
Personal exposure within the past 9-12 months
Personal exposure within the past 12+ months
I would be willing to get a Covid test if I was asked
I would not be willing to get a Covid test if I was asked
Re: Covid Vaccine
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please click all that applies
I got the vaccine
I didn't get the vaccine
I plan to get the vaccine
I plan to get a booster shot
I don't plan to get a booster shot
I had no side effects from the vaccine
I had specific side effects from the vaccine (and will list them below)
I got the Pfizer Vaccine
I got the Moderna Vaccine
I got the Johnson & Johnson Vaccine
Vaccine side-effects?
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If you got the COVID vaccine and you experienced any type of side effect, or if it is ongoing, please make a note of that here. If you did not get the vaccine, please note that instead. Thank you.
2024 Pulse
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Please click all that apply... You may select more than one.
I only want to work with Kambo Care privately
I would like to come together with a loved one
Not applicable to me
Are you currently taking any herbs, medications or supplements?
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PLEASE LIST ALL SUPPLEMENTS, ALL HERBS + ALL MEDICATIONS THAT YOU TAKE EVEN IF YOU DO NOT THINK THERE COULD BE A CONTRAINDICATION. THANK YOU!
Have you ever experienced depression or anxiety? Does anyone in your family?
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If so, please be specific below.
Are you pregnant or breastfeeding?
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Yes
No
What is your diet like?
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Please be specific. What do you eat?
How many glasses of water do you drink per day?
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none
1-2
3-5
6-8
9-11
12+
Have you done any type of food, juice, water etc. cleanse recently? Had an enema or a colonic? Please explain and when.
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ADDITIONAL Blood Pressure questions
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In order for your application to be considered valid, prior to doing work with us, you must be willing to test your blood pressure. Most drug stores have monitors for sale or for use.
I can confirm my answer is honest regarding my blood pressure
I know my blood pressure and highlighted that above in my application already
I don't know my blood pressure
I don't know my blood pressure and I will have my blood pressure taken
I understand for my application to be valid I must share accurate and honest blood pressure information with Kambo Care
Have you ever experienced lab drugs like LSD or MDMA?
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If you would like to experience this work with a friend or loved one, what is their name?
What do you do for a living?
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Do you like it?
Do you work online/remotely? Or in person with others?
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Date of Birth?
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Email Address
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Please confirm e-mail address
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Can we text the phone number provided to reply to your application?
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yes
no
Anything else to add or ask? Let Kambo Care know! We appreciate your transparency!
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By filling out this application you accept liability for yourself. Can you comply and accept responsibility?
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Are the answers you provided honest?
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