Breathwork Medical & Consent Form

Step 1

Your details

Full name *

Email address *

Phone number

Date of birth

Address

Emergency contact name

Emergency contact phone

Step 2

Health screening

Certain conditions can be contraindications for conscious connected breathwork, or may simply mean we adapt the practice for you. Nothing here rules you out on its own.

Do any of these apply to you, now or in the past?

I am currently pregnant or breastfeeding

Physical, mental or emotional health conditions

Include anything a facilitator should know about, even if it feels minor.

Medications you are currently taking

Allergies

Previous experience of breathwork, therapy or strong reactions

GP or primary healthcare provider

Anything else you'd like us to know

Step 3

Waiver & consent

Please read each statement carefully and tick to confirm you understand and agree.

Participation & personal responsibilityI understand that I am ultimately responsible for my own physical, mental and emotional wellbeing and for any consequences arising from my participation. It is my responsibility to communicate my needs, to pause or stop if I feel unwell, and to decide what is appropriate for me at all times.Health & medical adviceI certify that I have sought and followed any relevant medical advice regarding conditions that could affect my participation, and that if I take medication or have medical concerns I will consult my doctor before taking part.Substance-free agreementI agree to arrive free from the influence of alcohol, recreational drugs or any mind-altering substances, except prescribed medication taken as directed by a healthcare professional.Nature of the practiceI understand that conscious connected breathwork is not a substitute for medical advice or care, does not constitute diagnosis, treatment or prescription, and is offered as a personal wellbeing practice.Release & waiverI participate voluntarily and at my own risk, and release Breathing Space, its facilitators and associated parties from liability for injury, loss or damages resulting from my participation, except where liability cannot be excluded by law.Privacy & dataI consent to Breathing Space storing this information securely and using it solely to support my safety and care. I can request a copy or deletion at any time.

Step 4

Signature

Sign below to confirm that everything you've shared is accurate and that you agree to the waiver above.

Sign here with your finger or mouse

Signed on 9 November 2026 by …

Questions or concerns? Mention them to your facilitator before the session begins.