DEC - BW004 - Sun-Thurs 9-13 December at 7pm Los Angeles

Beginners' Workshop: Registration & Payment

12 - 16 June 8.30pm NY, 5.30pm LA
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First Name*
Last Name*
E-mail*
Location*

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Birth Date*

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Primary Phone Number*

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Health Information
Primary health concern(s)*
Name of Doctor
Do you, or have you in the past suffered from any of the following symptoms or conditions (please tick relevant):*

Allergy environmentalAllergy foodAnaemiaApathyAsthmaBuzzing earsChest pain (not around the heart)Chronic fatigueCoughingDeterioration of hearingDeterioration of visionDiabetesDryness in mouthEmphysema & COPDEpilepsyFear of sultry airFear without reasonFlashes before the eyesHeadachesHigh blood pressureHypoglycemiaInsomniaIrritabilityKidney diseaseLack of concentrationLoss of feeling in the limbsLoss of smellMental fatigueMigraine headachesPantingProne to colds and fluSchizophreniaShort temperShuddering in sleepSudden physical exhaustionTightness around chestTremblingVaricose veinsWeight gainsWeight lossOther
Medications : name and dosage*
For how long have you been taking each medication?
Medical history : trauma, accident, surgery*
You will receive an email email containing information about the Beginner Workshop, the LOGIN to the online meeting room via Zoom and instructions for the first session.

A member of our team will call you if you are having difficulty logging in.
By completing this form you agree to Learn Buteyko sharing your details
with Learn Buteyko Practitioners.

We will not give or share your details or personal information with third parties.

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1 Person$75.00

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Beginners' Workshop: Registration & Payment

Personal information

Health Information