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Breathwork Request Form

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First Name

Pronouns

Phone

Session Style:

Therapeutic Breathwork

Daily Practice (Pranayama)

Last Name

Email

Are you new to breathwork?

Yes

No

Please share any energetic, physical, medical, etc needs or concerns I should be aware of

Please provide me with an emergency contact and what you would like for me to call you should I need to contact them

I agree to the terms & conditions

I'll be in touch soon to schedule your session!