Client Intake CLIENT INTAKE FORM Full name Phone Email Birth Date Address Emergency Contact Name Emergency Contact Phone How did you hear about us?(Optional) Service Requested Choose Service... Private Session Partner Session Group Session Unknown Opt in to receive email marketing campaigns and newsletters from Breathwork Healing. I have read and accept the Terms and Coditions* Submit Thank you for submitting your Client Intake Form. As per the waiver you have agreed upon, you must speak with your doctor before doing Breathwork if you have any of the following conditions: A history of cardiovascular disease, including angina or heart attack High or low blood pressure or use of a pacemaker Glaucoma or retinal detachment Osteoporosis Significant recent physical injuries or surgery Mental illness or seizure disorders or for persons using major medications A personal or family history of aneurysms If you are pregnant or suspect you are pregnant Submit
