Pre-Breathwork Questionaire

Please Complete this Questionaire and Waiver Before Your Breathwork Session 

Your best email so we can send you the zoom link
Your cell in case we don't receive email confirmation


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Lifestyle & Medical History


Emergency Situations Outside of business hours: in the case of an emergency, I should call 911 or whatever emergency service is available in the location, and should go immediately to the closest emergency room. 

DUANE DENTON does not process insurance claims.

A 24-hour notice of cancellation of appointments is required. Full payment of a scheduled session will be due at least 24 hours prior to the appointment. If payment is missed or session is canceled late, payment will be due in full.

I certify that I am a competent adult of at least 18 years of age or that if I am a minor under the age of 18, I understand that the consent of my parent/legal guardian/person having legal custody will also be required before treatment.

This Informed Consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assignees.

I certify that I am in adequate physical, emotional and mental health to participate in a Breathwork session (If not, please specify on the opposite side).

I acknowledge that should this information change, it is my sole responsibility to notify my Breathwork Facilitator (DUANE DENTON).

I consent to and authorize DUANE DENTON 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 DUANE DENTON 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.

As a Breathwork Facilitator, DUANE DENTON offers information of a general nature to help clients in their journey toward greater self-awareness, mind-body connection, emotional, mental, physical, and spiritual wellbeing and DUANE DENTON assumes no responsibility for how I (the client) may use this information.

Breathwork is not recommended for people with 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 with DUANE DENTON. I will not hold DUANE DENTON or any associated companies or members of their staff responsible for any errors or omissions that I may have made in the completion of this form.

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