Enrollment Form

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To get us started, may you please tell me your first name?* This field is required.
First Name
Last Name
2
What is a good email address to reach you at?* This field is required.
example@example.com
3
What is your phone number?* This field is required.
Please enter a valid phone number.
4
Have you ever used a video calling platform before?* This field is required.This includes both personal calls (with friends and family) and video calls with a doctor (telemedicine).
YESNO
5
Which video calling platform(s) have you used?* This field is required.Please select all that apply.
Zoom
Google Meet
Skype
FaceTime
I don't remember the name of the video calling platform
Other
6
Thanks! Please take a look at our Terms of Service & Privacy Policy.* This field is required.Unfortunately, we’re required to make them long and complex, but the bottom line is that we take our relationship with you very seriously.
I accept
I do not accept
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Great! Let's start exploring which program is best for you. What condition have you been diagnosed with?* This field is required.Please select all that apply.
Chronic Obstructive Pulmonary Disease (COPD)
Emphysema
Chronic Bronchitis
Asthma
Interstitial Lung Disease (ILD) / Pulmonary Fibrosis (IPF)
Other
8
Do you live in Arizona?* This field is required.At the moment, our program is only available to residents of Arizona.
YESNO
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Unfortunately, we do not have a program to fill your needs at the moment, but are actively working expanding so that we can help people like you. Would you like us to let you keep you updated as we continue to expand our program offerings?* This field is required.
YESNO
10
Do you require physical assistance from another person to help you with standing up from a chair or walking?* This field is required.
YESNO
11
Have you ever experienced or been diagnosed with any of the following?* This field is required.Please select all that apply.
Sudden cardiac arrest in the last 6 months
Admitted to the hospital for heart failure in the last 6 months
History of any significant psychological or neurological conditions that limits your ability to participate in physical training
An untreated Abdominal Aortic Aneurysm (AAA)
History of Pulmonary hypertension
None of the above
12
Please select one of the following options to best describe your shortness of breath.* This field is required.
I only get short of breath with strenuous exercise
I get short of breath when briskly walking or walking up a slight hill
I walk slower than people of the same age because of my shortness of breath or I have to stop for breath when walking at own pace
I stop for a breath after walking for a few minutes
I am too short of breath to leave the house or I get short of breath when dressing
My shortness of breath is always a limitation, even while sitting
13
Our group sessions are held Monday mornings at 9:30AM PST (Pacific Standard Time). Does this time work for you?* This field is required.
YESNO
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Please select all the times that you are available for a group session.* This field is required.All time selections are in PST (Pacific Standard Time).
Monday 8AM
Monday 9AM
Monday 10AM
Monday 11AM
Monday 12PM
Tuesday 8AM
Tuesday 9AM
Tuesday 10AM
Tuesday 11AM
Tuesday 12PM
Wednesday 8AM
Wednesday 9AM
Wednesday 10AM
Wednesday 11AM
Wednesday 12PM
Thursday 8AM
Thursday 9AM
Thursday 10AM
Thursday 11AM
Thursday 12PM
Friday 8AM
Friday 9AM
Friday 10AM
Friday 11AM
Friday 12PM
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Click the Play button below to hear from Kali, a Physical Therapist here at BreatheSuite, on why we think the program might be right for you!
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We think you're ready to participate! The next step is to sign up for the Enrollment Session, which will give you an overview of the program, what to expect, and how to make best use of the BreatheSuite Virtual Pulmonary Rehab program. This will be a live presentation from our team, so you don't need to worry about having your camera or microphone on. You will have the opportunity to ask questions using the chat feature if you need to.

We can't wait to meet you!
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Book your BreatheSuite Enrollment Session* This field is required.This enrollment session is your first step of the BreatheSuite Virtual Pulmonary Rehab Program to get you started. The session will give you an overview of the program, what to expect, and how to make the best use of the BreatheSuite Experience. We can't wait to meet you!
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