Name
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First Name
Last Name
Phone
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Country
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Email
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Do you have any diagnosed conditions, illnesses, allergies, addictions, recent surgeries or other medical concerns?
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EMERGENCY CONTACT DETAILS
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First Name
Last Name
My relationship to this person
Contact Person's Phone Number
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Safety Waiver
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This Informed Consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assignees.
I confirm that I am in adequate physical, emotional and mental health to participate in a Breathwork session.
I acknowledge that should this information change, it is my sole responsibility to notify my Breathwork Facilitator. I consent to and authorize the facilitator to guide me in a Breathwork Session as specified by my facilitator. This session may include energy healing, vocal toning, tapping, touch work and integration coaching support. I understand that the facilitator is not a licensed physician or functional breathing specialist and does not dispense medical advice or prescribe the use of any technique as a form of treatment for any physical or psychological conditions without the advice of a physician - either directly or indirectly. I understand the information offered is of a general nature to help clients in their journey toward greater self-awareness, mind-body connection, emotional, mental, physical, and spiritual wellbeing and the facilitator assumes no responsibility for how I (the client) may use this information.
Before commencing your Breathwork session, please inform your breathwork facilitator if you have a personal or family history of: Epilepsy, seizures, cardiovascular problems including angina or heart attacks, high blood pressure, aneurysms, glaucoma, retinal detachment, osteoporosis, or recent physical injuries, surgery or illness - particularly involving the brain, mouth, teeth, nose, throat, thyroid, immune system, lymphatic system, lungs, chest, ribs, spine, neck and/or reproductive organs. Breathwork is not recommended for people with a personal history of mental illness, personality disorders, hospitalization for any psychiatric condition or emotional crisis, suicidality, psychosis, drug or alcohol addiction. Possible side effects may include dizziness, fainting, changes in body temperature, disorientation, tingling, carpopedal spasms, cramping, emotional breakthroughs, feeling physical, mental, energetic and/or emotional triggering and/or vulnerability.
The nature of the service/session has been explained to me and/or is available to me in writing and any questions I had regarding the session(s) have been answered to my satisfaction. I understand that the session may involve risks of complications or injury from both known and unknown causes, and I freely assume these risks.I understand that I have the right to refuse to participate in the session. No guarantee, warranty or assurance has been made to me as to the results that may be obtained. I certify the above information is correct to the best of my knowledge.
I agree to adhere to all safety precautions and regulations during my treatments/sessions and will not hold the facilitator or any associated companies (including Owaken Breathwork) or members of their staff responsible for any errors or omissions that I may have made in the completion of this form.
Emergency Situations: in the case of an emergency, the facilitator can call 111 or whatever emergency service is available in the location, and assist you to go immediately to the closest emergency room.
I consent to this Safety Waiver by signing my name below and submitting this form:
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First Name
Last Name
One last thing - During our breathwork gathering, we may take a few photos or short videos to capture the magic of the experience - our main reason is to normalise breathwork as a healing modality and to show others that vulnerability and emotional expression is absolutely okay and a necessary part of life. We may share this on social media platforms, our website, or for other promotional materials. By checking the box below, you're letting us know you're okay with being included in any photos or videos taken during the event. Of course, if you'd prefer not to be recorded, we completely respect that! If you change your mind at any time, just let us know before the event.
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Date Signed
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