First Name *Last Name *Phone Number - What'sApp Email *By ticking the box you confirm that you are 18 years old or more *Please confirm that you are 18 years old or moreI want to attend March 24 - Kambo Group Ceremonyprivate sessionclosed private groupIMPORTANT NOTE: If you have any health conditions or take any medications please email us at kambo@greenheartretreats.org to discuss your suitability for participating in a Kambo ceremony before you make a booking. Medications can not be taken in the morning of the day you take Kambo and some medications have to be stopped with doctor's permission up to one month before. Some health conditions make it very unsafe to participate in a Kambo ceremony. *Please check the box to indicate that you have read and understood the above information.Address *Zip/Postal *City *Country *Birth Date yyyy-mm-dd *Gender *FemaleMaleWhat would you like to focus on - Mental Health General Mental HealthMental AbuseEmotional PainPast TraumaRelease NegativityWhat would you like to focus on - Physical Health General Physical HealthDetox / CleansingPhysical PainMigranesPhysical AbuseSexual AbuseAddictionWhat would you like to focus on - Health and Well-Being Life PurposeCareer ChangeCreativityPersonal GrowthLearningCuriosityHeart CenterOther areas you want to focus on Medical History Information - Physical Health DiabetesEpilepsy or SeizuresVisual ImpairmentInfectious DiseasePhysical DisabilityThyroid ConditionsEhlers-Danlos SyndromeAddison’s DiseaseUndergoing chemotherapy or radiation therapyPhysical Health Details & Medications *Please provide details if you check any condition. Include diagnosis history, any past and current medications including dosage and time on meds. Enter "none" if none of the above have been checked.Recent injuries, surgeries or active disabilities Medical History Information - Heart Health High Blood PressureLow Blood PressureCirculatory ProblemsStrokeHeart AttackIrregular HeartbeatAneurysms or Blood clotsBrain HaemorrhageHeart Health Details & Medications *Please provide details if you check any condition. Include diagnosis history, any past and current medications including dosage and time on meds. Enter "none" if none of the above have been checked.Medical History Information - Mental Health Mental DisorderAnxiety DisorderClinical DepressionMultiple Identity Disorder (MPD)BipolarSchizophreniaSuicidal IdeationSelf HarmingOCDADHD / ADDPTSDAutismAlcoholism or Drug AddictionMental Health Details & Medications *Please provide details if you check any condition. Include diagnosis history, any past and current medications including dosage and time on meds. Enter "none" if none of the above have been checked.Please list any other medications you are currently taking including the dosage and time on medications. *Enter "none" if you aren't currently taking any medications.Please list any other medications you have taken in the past. Include when you took them and how long you were on them. *Enter "none" if you haven't taken any medications in the past.Please list any vitamins or supplements you are currently taking. *Enter "none" if you aren't currently taking any vitamins or supplements.Do you have any severe or potentially life-threatening allergies that would require the use of an epi pen? *YesNoPlease describe your allergies. *If you have any allergies, please describe them in detail. If this does not apply to you, write "none".Please list any recreational drugs you currently use. *Enter "none" if you do not currently use any recreational drugs.Please list any recreational drugs you have used in the past. *Enter "none" if you have not used any recreational drugs in the past.Are you currently pregnant? *YesNoPregnancy Disclaimer: I understand that Kambo is a purgative and can cause a miscarriage. I understand that Kambo is not recommended while breast feeding a child under the age of six months. If I become pregnant before the session, I understand that I am responsible for notifying Green Heart and that I will not be able to participate in a Kambo ceremony. *By clicking here, I agree with the above.Green Heart Health Screening & Full Disclosure: We carefully screen each client for their safety prior to attending a Kambo ceremony. All herbal supplements, natural medicines, and medications (prescription and over-the-counter) must be disclosed and subsequently approved for use by Green Heart. All herbal supplements, natural medicines, and medications (prescription and over-the-counter) cannot be taken in the morning of the day you attend the ceremony, with the exception of birth control pills. You hereby agree that all information you provide in the application is correct and current and that you have disclosed all physical and psychological conditions as well as all herbal supplements, natural medicines and medications (prescription and over-the-counter) that you are taking. In some cases, you will be contacted personally by one of our staff to ensure that you are prepared for the experience. Green Heart is not a medical facility and its owners and staff are not licensed medical doctors, psychologists, or psychiatrists. We do not practice medicine, diagnose, cure, or treat disease or illnesses. Instead, we function as spiritual guides and teachers and offer ceremony for the purpose of spiritual communion and growth. Dietary Restrictions: The day before Kambo we recommend you to restrain from all kind of refined sugar, red meat, non organic and processed foods. You will be advised of all restrictions a few days before your Kambo ceremony. Each specific set of restrictions should be followed. Consumption of alcohol is not allowed 48 hours before you arrive, the time of restriction for street drugs can vary from 48 hours to 6 weeks and some drugs are contraindicated. *Check this box if you agree to the Green Heart Health Screening and Full Disclosure.Green Heart Medications Note: For your safety the Green Heart practitioners have a "no medications / vitamins / supplements policy" the morning of a Kambo ceremony (this does not include birth control pills). Medical studies have shown that mixing medications and some supplements with Kambo can be dangerous and potentially fatal. Green Heart representatives are not licensed to give advice on prescription medications. If you are currently taking medications, please consult with your doctor before discontinuing any medications. *Check this box if you agree to the Green Heart Health Medications Note.Have you attended a Kambo ceremony with us before? *YesNoHow many times? When was the last time? What were the results? Have you attended a Kambo ceremony with anyone else? *YesNoWith whom? Where? When? How many times? What were the results? Please read and agree to the terms indicated here: By checking the box and typing my name in the field below, I attest that I have read and understand all of the above written medical information and have openly disclosed all requested health and medical facts. I attest that the information provided above is true and complete, to the best of my knowledge. I understand that falsifying or omitting any relevant information may be grounds for denying my attendance at the ceremony for which I am applying, with or without a refund, at the sole discretion of Green Heart, I hereby waive, release and hold harmless Green Heart from any and all liability or responsibility for all injuries and/or damages or claims which may occur in the event I do attend the ceremony. *I accept the terms and conditions.I understand that if I don't show up for the ceremony or cancel my booking within 24h before the ceremony starts, I will not be refunded my 500 SEK deposit. You will be asked to pay the deposit when this questionnaire has been approved and your booking is confirmed. *Check this box if you agree to the Green Heart refund policyHave you been vaccinated for Covid-19? Yes, more than 6 weeks agoYes, less than 6 weeks agoNoPlease type your name in CAPITAL letters: *MessageSubmit