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RebirthRetreat2023-RiverSiobhan-Sensation

kambo application

Health Declaration

Please fill out the following form
in order to participate in our activity.

First name

Last name

Date of Birth

Phone

Street Address

City

Region/State/Province

Postal / Zip code

Please describe in detail all of your current physical health symptoms: heart health, brain health, gut health, etc.

Any current medical condition, illness, or injury?

Yes

Any current medications/drugs?

Yes

Please describe in detail all of your current medications/drugs.

Any history of fainting, siezures, stroke, or brain injury?

Yes

Any history of abnormal heart symptoms or abnormal blood pressure?

Yes

I declare that the information I’ve provided is accurate & complete.

I take full legal responsibility for my choice to participate in Kambo and have chosen to consent to the risks, which I have been informed about through this website.

Signature

Thanks for submitting!

Emergency Contact Form

YOUR OWN DETAILS:

First name

Last name

Phone

YOUR EMERGENCY CONTACT DETAILS:

Contact First Name

Contact Last Name

This contact is my

Contact Phone Number

Contact Email

Thanks for submitting!
We’ll contact this person only in case of emergency.

any other questions?

Get in touch so we can assess your specific needs.

First Name

Last Name

Message

Thanks for submitting!

I accept terms & conditions

Thanks for submitting!

NOVA ROSE

Portland,
Oregon

San Miguel de Allende, Mexico

Seattle,
Washington

Baja,
Mexico

The content on this website is provided for educational purposes only and is in no way substitute for medical advice from a licensed naturopath or doctor.

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