Kambo Intake Form · Primal Coherence

Section 1 — Pre-session guidelines

Please read the following carefully. Mixing Kambo with any of the following could be extremely dangerous.

Alcohol or drugs within 72 hours before and 7 days after.
Do not fast longer than 18 hours in the 7 days before or after Kambo — this includes juice fasting. Maintain a normal eating pattern in the days leading up to your session, then fast for the 12 hours immediately before it — no food, water only.
Do not begin any colonics, enemas, water-based detox, liver flushes, saunas, hot tubs, or sweat lodge 3 days before or after Kambo.
Do not consume large amounts of water before arriving. I will give you water at the session, at the right time and in the right amount.
No other strong plant medicines within 24 hours of your session.

I have read and understood the guidelines above regarding what should be avoided before Kambo.

Section 2 — Contraindications

You cannot receive Kambo if any of the following apply to you. If you are unsure whether something here describes you, ask me before you book rather than guessing.

Serious heart problems or heart disease, or any heart surgery — including bypass, valve replacement, a pacemaker, or an implanted defibrillator. (Stents are fine.)
Pericardial effusion.
Medication for low blood pressure.
History of stroke or brain hemorrhage.
Aneurysms or blood clots.
Ehlers-Danlos syndrome.
Severe mental health conditions, including bipolar disorder, schizophrenia, or psychosis. (Depression, PTSD, and anxiety are not contraindications.)
Inability to make a voluntary, informed decision to receive Kambo.
Currently undergoing chemotherapy or radiotherapy, or within 4 weeks afterward.
Taking immunosuppressants for an organ transplant.
Addison's Disease.
Current and severe epilepsy.
Recovering from a major surgical procedure.
Under 18 years old.
Pregnant, potentially pregnant, or breastfeeding a child under 6 months old.

I have read the contraindications above and confirm that none of them apply to me. I understand the risks involved should I choose to disregard this information.

Section 2b — Tell me before you book

None of these rule you out. They change how I plan your session, so I need to know about them in advance. Note them in the health history box below.

An autoimmune condition, or immunosuppressants taken for one.
Currently undergoing immunotherapy.
Active addiction to any substance, including alcohol, benzodiazepines, heroin, methamphetamine, or research chemicals.
A daily diuretic — or a medication that is also a diuretic but is not required daily.
Fertility treatment, or actively trying to conceive.
A history of disordered eating, or a pattern of restrictive eating. This protocol involves fasting.
Slimming or sleeping supplements, including melatonin.
Epilepsy that is not current and severe.
Liver or kidney disease.
Diabetes, or any condition affecting blood sugar.
Any heart, blood pressure, or neurological condition not already listed in Section 2.
A previous Kambo session that was difficult, stopped early, or involved fainting.

I have read the list above and disclosed anything that applies to me in my health history below.

Section 3 — Release of Liability

Primal Coherence · Kambo Session — Release of Liability & Assumption of Risk

Kambo is the peptide secretion of the Phyllomedusa bicolor frog. Jane Savina Gardner is not a licensed medical provider and does not diagnose, prescribe, treat, or cure any condition. Kambo is not a substitute for medical care — please see a physician for any illness or disease. In an emergency, call 911.

Directions. I’ll follow Jane’s instructions before, during, and after my session.
Risk & release. Kambo produces strong physical effects that usually pass within 20–40 minutes: raised heart rate, flushing, head pressure, tingling, nausea, chills, cramping, vomiting, and tetany. I accept the inherent risks, take responsibility for my own wellbeing, and release Primal Coherence and Jane Savina Gardner from any injury, loss, or damage arising from my participation.
No duress. I’m signing freely and have had a fair chance to read this.
Indemnification. Plain terms: if something goes wrong, you agree not to hold me or my practice financially responsible. For myself and my heirs, assignees, representatives, and next of kin, I release, indemnify, and hold harmless Primal Coherence and Jane Savina Gardner, their agents and employees, from any injury, disability, death, loss, or damage — whether arising from negligence or otherwise — to the fullest extent permitted by law.
Enforceability. If any part is unenforceable, the rest stands.
Disputes. Good-faith negotiation first; anything unresolved goes to binding arbitration.

I have read and fully understand the Release of Liability and Assumption of Risk Agreement above and voluntarily agree to its terms.

Your information

Full name *

Date of birth *

Phone number *

Emergency contact name & phone number *

Current medications (name and dosage) *

Anything else about your health history your practitioner should know *

Your intentions

Kambo meets you where you are, and it helps Jane to know where that is before you walk in. There is no right answer to either of these and no length requirement — a sentence is plenty, and whatever comes first is usually the true one.

What brought you to Kambo? *

What are your intentions for this ceremony? *

Electronic signature

By typing your full name below, you are signing this document electronically. You confirm that you have read all sections of this waiver, that none of the contraindications apply to you, and that you are voluntarily consenting to receive Kambo at Primal Coherence. Your typed name constitutes your legal electronic signature.

Type your full name to sign *

Date signed *

By checking here, I consent to the use of my electronic signature in lieu of an original signature on paper. I confirm that all information provided in this form is accurate and complete to the best of my knowledge.

Your submission is sent securely to your practitioner.
You will receive a confirmation once it has been reviewed.

Received 🌿

Thank you for completing your Kambo intake form. Jane will review it before your session.
Questions? Text (443) 254-6762.