Shamanic Breathwork Participant Consent and Health Form

Shamanic Breathwork Participant Consent and Health Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Emergency Contact Name and Number*
Do you currently have or a history of any of the following?*

Heart or cardiovascular conditionsPregnancyRecent surgery or injuryRespiratory conditions eg asthmaMental Health conditions requiring supportnone of the above
If yes, please provide details
Signature*
Should be Empty: