Kambo Waiver & Contraindications Agreement — William Wisner
Gateway Kambo Kambo Waiver & Contraindications Agreement Practitioner: William Wisner  ·  7003 Spavale Dr, High Ridge, MO 63049
Your waiver has been received.

Thank you for completing this agreement. We look forward to holding space with you.

I
Participant Information
Required
Required
Valid email required
Required
Required — must be 18 or older
II
Purpose and Use of Kambo

Kambo is a traditional Amazonian medicine that involves applying the secretion of the Phyllomedusa bicolor frog onto small burns on the skin. It is a non-psychoactive substance and is used by various cultures in healing practices.

III
Your Intention

Understanding what brings you to Kambo helps your facilitator prepare and serve you well. This information is confidential and used only to support your session.

Please share your intention before continuing
IV
Contraindication Agreement

Check any of the following that apply to you. If any item applies, you may not be eligible for Kambo and must contact your facilitator before proceeding.

V
Substance Guideline List

The following substances must be abstained from before and after a Kambo session. Please read each guideline carefully, then confirm your understanding with the acknowledgment below.

Substance Before session After session
Alcohol (High Doses)48 Hours7 Days
Alcohol (Low Doses)12 Hours24 Hours
Amphetamines (Adderall, Ritalin)7 Days7 Days
Anti-ConvulsantsMust discuss with facilitator
Anti-PsychoticsContraindicated
Ayahuasca & Analogues24 Hours24 Hours
Benzodiazepines (Valium, Diazepam)18 Hours8 Hours
Beta BlockersDo not take morning of8 Hours
Blood ThinnersDo not take morning of8 Hours
Botox7 Days7 Days
Bufo24 Hours6 Weeks
Cannabis12 Hours24 Hours
Cocaine3 Days5 Days
Crack Cocaine7 Days7 Days
Ecstasy (MDMA)7 Days7 Days
FentanylContraindicated
Heroin14 Days14 Days
Methamphetamine30 Days30 Days
Morphine / Oxycodone5 Days5 Days
LSD48 Hours72 Hours
Psilocybin24 Hours24 Hours
Tramadol48 Hours24 Hours
Vasoconstrictors (Triptans)3 Days12 Hours
Covid Vaccine30 Days7 Days
You must acknowledge the substance guidelines to continue
VI
Liability Release and Assumption of Risk

This waiver includes a comprehensive release of liability clause, stating that the participant agrees to participate voluntarily and assumes full responsibility for any outcomes.

The practitioner and the organization they are affiliated with are absolved of all responsibility for any potential injuries (physical or psychological) or death resulting from participation in a Kambo session, regardless of circumstances or disclosed health information.

The participant acknowledges that they are voluntarily engaging in this practice at their own risk. By signing below, the participant affirms that they have been fully informed of the nature of Kambo, its potential risks and effects, and that they are choosing to participate of their own free will.

The participant further acknowledges that no guarantees have been made regarding outcomes or results, and that the facilitator's role is solely to support the process. Nothing in this session constitutes medical or psychological advice or treatment.

VII
Agreement and Signature

By signing below, you confirm that you have read, understood, and agree to the terms outlined in this document, and that you are participating voluntarily in the Kambo ceremony.

You must acknowledge and agree to continue
Required
Required
Draw your signature
Signature is required
VIII
Pre-Session Consultation

Before every session, Gateway Kambo requires a brief consultation call — by phone or video — with your facilitator, William Wisner. This call is not an additional screening; it is an opportunity to review your intake, discuss your intention, address any questions, and ensure your session is tailored to serve you as well as possible.

William will reach out to schedule your consultation after reviewing your completed waiver. Most calls are 15–30 minutes.

Please select a preference
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Submitted securely to gatewaykambo@gmail.com

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