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Kambo Waiver
I certify that I am seeking the consultation and services of Jetta Blaine of Moonflower Insights 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.

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.

I certify that I have read and understand the prep sheet.

Please respond to the following:
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Email *
First & Last Name
Preferred Pronouns
Date of Birth
Email Address
Are you under the age of 18?
Have any type of blood clot, brain or heart aneurysm, heart issue/condition/ disorder or arrhythmia?
Chemotherapy or radiotherapy within the last 30 days?
A history of seizures, current or severe epilepsy, or cardiovascular issues?
Are you pregnant or could potentially be pregnant and/or breastfeeding?
Have you worked with or used 5meoDMT (bufo), Iboga (Ibogaine) or any other plant medicine within the past 90 days?
If yes, when:
Please list any supplements/medications taken regularly:  
Please list any recreational drugs taken in the last 30 days:
Medicine for low or high blood pressure?
Serious mental health issues, not including depression, anxiety, or PTSD?
Taking immunosuppressants for an organ transplant?
Recovering from major surgery?
Low levels of cortisol in your blood?
Have Esophageal varices, Addison’s Disease, Pancreatitis,  Ehlers-Danlos Syndrome?
Have severe Epilepsy?
Are recovering from a major surgical procedure?
Have suffered eating disorders?
Have been addicted to drugs?
Do you have history of drug addiction? Please explain:
Is this your first time sitting with Kambo?
If no, how many times have you sat with Kambo?
What is your intention for sitting with Kambo?
Is there anything else I should know prior to your treatment?  
Would you like to be added to my email list for retreats & group sits?
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Cautions before and after taking kambo: Caution is also required in the following cases: People taking immune-suppressants for autoimmune disorders. 
People taking slimming AND sleeping supplements.
 Active drug or alcohol addiction.
 Long term or water fasting for 7 days before or after Kambo other than required fasting.
 Colonics, Enemas, liver flushes or any water based detox should be avoided within 3 days either side of taking Kambo. Please let me know if you have concerns about any of the above. Discomforts and Risks: Though kambo is safe for most people, the following discomforts and risks could be associated with your kambo treatment.  Some discomfort may follow for 1-5 days after taking kambo.  Most are resolved by the next day, however, some may persist longer. Some discomforts may include, nausea, vomiting, headache (due to toxin release or tension), feeling some fatigue and sleepiness, and possible depression.  Please note that this can just be a process and usually resolves within 1-5 days.There are some risks, that if you have an existing condition, you may experience a Herxheimer effect, which is when the symptoms get worse before getting better - much like when you are detoxing. 

 If after kambo you experience dizziness, pain or vomiting blood, please call your practitioner and seek medical attention. Before making the decision regarding participation in this Kambo treatment you should have reviewed the information in this form, had the opportunity and ask any questions you may have. Your signature below means that you have received this information, have asked the questions you currently have about the treatment and those questions have been answered.

 Participant: By typing your name below, you indicate that you are voluntarily choosing to take part in this Kambo treatment & have answered this waiver truthfully. This hereby satisfies as a signature:   *
Other Agreements

Cancellation Policy: Kambo is a commitment to one's self-growth and well-being. As a result, the following cancellation policy applies:

 A nonrefundable deposit of $75 is due per ceremony at the time of booking to affirm commitment to Kambo & secure the date in my calendar ($225 for inoculations (75 x 3)). This goes towards the overall cost of your ceremony. This price may vary based on experience. 

Ceremonies can be transferred once with a 72-hour notice. If a ceremony is cancelled or transferred 24-72 hours prior to ceremony, the deposit will be lost and a new deposit will be required to book another ceremony. 

If a ceremony is cancelled or transferred 24 hours or less prior to ceremony, the recipient is required to pay for the cancelled ceremony in full prior paying an additional $75 deposit to secure a new ceremony. They will also need to pay their entire balance 72 hours prior to their ceremony or it will be cancelled and the deposit will be lost. 

Deposits/prepaid ceremonies expire 6 months after initially paid, regardless of transfers. Trades/credits apply.

There are no refunds for ceremonies, retreats, or any other of my services.

Time Commitment Policy: While most ceremonies conclude within 2-2.5 hours, there are occasional instances where ceremonies may extend beyond this timeframe. Should a ceremony exceed 3 hours, the client will be required to cover an additional ceremony fee of $300.

Participant: By typing your name below, you indicate that you hereby understand and agree to the cancellation policy & consent to the time commitment policy
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