INFORMED CONSENT FORM
Kristine Ovsepian

We ask that you read all the information we have sent to you to make sure that you qualify to take a kambo treatment.  Your signature is required on this form to show that you understand the discomforts and risks, and agree to take part in the treatment.  

Some of the essential information you will need to know to participate in the treatment has been outlined below.  

Contraindications:

• Serious heart condition
• Had a stroke
• On medication for low blood pressure 
• Had a brain hemorrhage 
• Had aneurysm or blood clots
• Lack the mental capacity to make the decision to take kambo
• Have severe mental health problems excluding depression and anxiety
• Undergoing  chemotherapy or radiotherapy for 4-6 weeks after
• Take immunosuppressants for organ transplant   
• Pregnant women
• Women who are breastfeeding a child under 6 months old
• Have Addison’s Disease
• Have Ehlers-Danlos Syndrome (EDS)
• Have severe epilepsy currently
• Recovering from a major surgical procedure
• Under 18 years of age

Cautions before and after taking kambo:

• Taking immunosuppressants for autoimmune disorders
• Taking slimming, serotonin, or sleeping supplements
• Active drug or alcohol addiction
• Long term or water fasting for 7 days before or after kambo treatment 

I confirm that I am of lawful age and fully understand the contents of this document.