Waiver Form - Please read everything below

Please do not assume that any medication, allergy or health condition is irrelevant or will not affect your suitability for Kambo.

It is essential that you fully and honestly disclose medical conditions, allergies, medications and supplements, including anything that is not specifically listed in the questionnaire below.

Even information that may seem insignificant to you could be extremely important when assessing your suitability and ensuring your safety.

I reserve the right to postpone, refuse or cancel your session if I have reasonable concerns that important information has been withheld, that your health disclosures are incomplete or inaccurate, or that you have not been fully honest with me.

Your honesty and transparency are essential for your safety. These requirements are in place to protect you as a client, the practitioner and the integrity of the medicine.

• At Anima Pacha Drums, your health, safety and wellbeing are always my highest priorities. I kindly ask that you take the time to read all the information and paperwork provided carefully and disclose all medications, supplements, medical conditions, allergies, previous health complications and any other relevant information, including anything that may not be specifically mentioned in the questionnaire.

• It is your responsibility as a client to provide complete, accurate and honest information before your session even.

• I reserve the full right to postpone, decline or cancel a session at any stage if I have reasonable concerns that important health information has been withheld, that your disclosures are incomplete or inaccurate, or that you have not taken sufficient time to read and understand the paperwork provided. This also applies if new information comes to light that may affect your suitability for Kambo, or if I believe proceeding could place your health or wellbeing at risk.

• These decisions are never made lightly. They are guided by my duty of care, professional responsibility and deep respect for the medicine and everyone who chooses to sit with it.

• The decision regarding whether Kambo is appropriate for you must not be made by you alone. As your practitioner, it is my responsibility to review your health information, consider potential contraindications and determine whether I am willing and able to facilitate your session safely.

• This process is intended to protect you as a client, while also respecting the medicine and safeguarding myself as a practitioner.

Important Information Regarding Health Disclosure, Safety and Contraindications

Travel Expenses

Please be aware that if I am required to travel a considerable distance (usually over 1 hour of travel) to facilitate your session, an additional contribution towards travel expenses may be requested. This will be discussed and agreed upon in advance.

Exceptions and Contraindications

Kambo is a powerful traditional practice that produces significant physical reactions and is not suitable for everyone. It carries potential risks, including serious adverse reactions, even when administered with care.

Certain medical conditions, medications and individual health circumstances may make Kambo particularly dangerous or unsuitable.

The contraindications listed below are intended to provide guidance and must not be considered an exhaustive list. If you have any medical conditions, take prescribed or non-prescribed medication, or have concerns about your health, you must disclose this information before your session.

Completing a waiver form does not automatically confirm that you are suitable to receive Kambo.

Your honesty and willingness to communicate openly are an essential part of our shared responsibility for your safety. Thank you for respecting this process and understanding that every question I ask comes from a place of care, compassion and responsibility.

PLEASE MAKE SURE THE FOLLOWING BOXES ARE FILLED IN

Please specify which treatment are you booking for:

Please specify if you are looking for in person session or online treatment

Please specify which month you would like to receive the treatment ( we will arrange a more accurate date via the e-mails)

1 Date of birth

2 Heart problems (heart attack, pacemaker…)

3 Do you suffer or suffered from Blood cloths?

4 Low / High blood pressure that is controlled by medication?

5 Do you suffer or suffered from fainting or dizziness?

6 Are you pregnant?

Add your text

7 Are you breastfeeding a child under 1 year old?

8 Do you suffer or suffered from Psychosis or Bipolar Disorder?

9 Are you suicidal or have serious Mental Health conditions?

10 Do you suffer or suffered from Addison’s Disease?

11 Did you had any organ transplant surgery?

12 Do you have issues with your Pancreas?

13 Are you on any Immune suppressants?

14 Are you on steroids?

15 Do you suffer or suffered from Oesophageal condition?

16 Do you suffer or suffered from Epilepsy?

17 Do you suffer or suffered from Stroke?

• If you answered ‘YES‘ to any of the above, please give as much information in the COMMENTS section below.

• It is essential that you fully an honestly disclose medical conditions, allergies, medications and supplements, including anything that is not specifically listed in the questionnaire below.

  Even information that may seem insignificant to you could be extremely important when assessing your suitability and ensuring your safety.

  I reserve the right to postpone, refuse or cancel your session if I have reasonable concerns that important information has been withheld, that your health disclosures are incomplete or inaccurate, or that you have not been fully honest with me.

1. I fully understand that Ilona Dovey at Anima Pacha Drums is not a licensed medical doctor, does not diagnose or treat disease, and that I am not here for medical or diagnostic procedures.

2. Suggestions and treatments offered for my well-being are not intended to take the place of qualified professional medical care, including the diagnosed treatment of named diseases.

3. I understand that assessment and suggestions regarding diet, nutritional supplementation, Shamanic healing, natural herbal detox and herb/compounds or preparations, remedies, essential oils offered here or elsewhere are based upon the observations through Shamanic training and are not intended to replace standard medical treatment or advice from licensed health care professionals.

4. I agree that all nutritional supplements, herbs, extracts, remedies, etc., are taken at my own risk. As with any ingested substance, an allergic reaction is a possibility in some individuals. I have been informed of the risks and consequences involved. I agree that I and my heirs, guardians, legal representatives and assigns will not make a claim or file any action against myself or any members of Anima Pacha Drums for injury or damage resulting from negligence or other acts, whatsoever, caused in connection with my consultation.

5. I also understand that Anima Pacha Drums will not be held responsible for errors/ ingredients on the part of any manufacturer or supplier of products offered here or elsewhere.

6. I hereby consent to authorise Anima Pacha Drums to practice Shamanic and Energy healing, Kambo Natural Detox and associated therapies such as Feather Stone energy healing or other alternative modalities that may be implemented upon reasonable assessment. I understand that these modalities may cause minor bruising, swelling, dizziness, tiredness, migraines, shallow bleeding or other mild effects. (These are normal reactions and not a cause for any concern.)

7. I understand that if I do not disclose certain medical conditions or health concerns to Anima Pacha Drums, it will be my responsibility, and I will take no legal action against Anima Pacha Drums.

8. Any information shared in sessions is confidential and will not be disclosed to any party, be they family or medical provider. However, for educational purposes, it may be shared anonymously with mentors and co-students.

9. Occasionally, Anima Pacha Drums may ask if you would allow them to take your photograph during any of the personal sessions offered, which then can be shared on the website or social media.

I have carefully read this agreement and fully understand the content. I am aware that this is a waiver and release of potential liability and a contract between Anima Pacha Drums and myself and sign it of my own free will.

I affirm that I have completed the health questionnaire honestly, provided all necessary information, and agree to all terms and conditions. By signing this form, I acknowledge that I have thoroughly read and understood this agreement. I recognise that it constitutes a waiver and release of potential liability, forming a binding contract between Anima Pacha Drums and me, which I enter into voluntarily.

Ilona Dovey

Anima Pacha Drums

07535749686

animapachadrums@gmail.com

www.animapachadrums.co.uk