Shonielay Client Consent Form

Vanta Breathwork Disclaimer
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Contact Information — Email*
Contact Information — Phone*

Area CodePhone Number
Health Screening Questionnaire
1. Do you have any current medical conditions? (Please specify)
2. Are you currently taking any medication? (Please specify)
3. Do you have a history of mental health issues? (Please specify)
YesNo
YesNo
YesNo
7. Do you have any allergies or sensitivities? (Please specify)
List of Unsuitable Persons for Treatment
Explanation of the Treatment
Side Effects
Touch in Therapy
Declaration
YesNo
I acknowledge the possible risks and side effects.I am satisfied with the explanation of the treatment and I wish to go ahead.
Client Signature*
Date of Signature*

MonthDayYear
Aftercare Advice
Consent Form Review
BELIEF CODING® — MASTER FACILITATOR COURSE DISCLAIMER
I have read the above.I agree and acknowledge that I am responsible for my own health and mental well-being and the course creator is not liable for my health, emotional state or mental well-being.
Name*

First NameLast Name
Signed*
Date*

MonthDayYear
Should be Empty:

Vanta Breathwork Disclaimer