Breathwork With Jenny Natyshak

BENEFITS
CLASSES
BIO
CONTACT

Before You Register

For A Breathwork Class

Please Fill Out The Waiver Below

You cannot attend a class without this waiver complete!

If you've already completed a waiver and/or do not need to update any medical info, you can click here.

General Medical Questionnaire

For Breathwork With Jenny Natyshak

Release of Liability Information

First Name *

Last Name *

Email *

Phone *

Emergency Contact

Emergency Contact Full Name *

Emergency Contact Phone Number *

Your Physicians Name

Your Physicians Phone Number

General

Have You Done Breathwork Before? *

YES

Has there been an event or an experience that you feel open to sharing that could support me, as your facilitator, to support you in a deeper way?

Have you been to the hospital in the last 12 months? *

YES

If "YES", explain.

Medical

Have you had OR do you presently have any of the following conditions? (CHECK IF YES)

Angina

Cardiovascular Disease

Heart Attack

High Blood Pressure

Glaucoma

Retinal Detachment

Osteoporosis

Seizure Disorders

Recent Injury or Surgery

Any condition for which you take regular medications

History of panic attacks

History of psychosis

Severe untreated mental illness

Family history of aneurysms

Frequent dizziness or vertigo

Are you currently pregnant?

Other

IF YOU SELECTED OTHER, PLEASE SPECIFY HERE:

If you have answered “Yes” to one or more of the above questions, you must consult your physician before engaging in meditative breathwork. Tell your physician which questions you answered “Yes” to.

After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

Please share a written confirmation from your physician if you are approved to participate in the breath session.

Full Name (SIGN BY TYPING YOUR FULL NAME) *

By typing your name above and checking this box you attest to the truthfulness of your statements and answers. I, as your facilitator, reserve the right to determine eligibility for engagement and participation in our program based upon the answers given.

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Payment

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Contact

Email & Address

Email: Jenny@TheLodgeAtLakeshore.com

Address

The Lodge at Lakeshore

Essex County Road 22, Emeryville, ON, Canada

1258 Essex County Rd 22, Emeryville, ON N0R 1A0, Canada

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