Client Waver Form
Welcome, and thank you for taking the time to read through this release and waiver. This document is an important step to ensure clarity and mutual understanding. It explains the nature of breathwork, outlines any potential risks, and confirms that you take personal responsibility for your own wellbeing during and after each session. By signing, you acknowledge that breathwork is a supportive but not medical practice, and you release me from any liability connected to your participation.
For the purposes of this Release and Waiver, the term “Releasees” refers collectively to:
Practitioner: Sam Roze
Entity: Breathe With Me
I, (“the Releasor”), acknowledge and agree that my participation in breathwork discussions, consultations, and/or sessions with the Releasees:
a) is not a substitute for medical care or advice from my doctor or primary healthcare provider;
b) does not provide medical guidance, diagnosis, prescriptions, or treatment for any health condition;
c) is intended as a supportive wellness practice only.
I understand that sessions may sometimes involve light physical touch to assist the process, and I have the absolute right to decline this at any point by saying “stop”.
I further acknowledge that if I am taking medication or have any medical condition – including but not limited to epilepsy, bipolar disorder, schizophrenia, heart conditions, or pregnancy – it is my responsibility to disclose this to the facilitator(s). While I may be accepted into a session, I remain fully responsible for any outcomes or consequences arising from my participation.
I confirm that I have sought appropriate medical advice regarding any physical, mental, or emotional condition that could affect my health during or after a breathwork session. I understand that I should consult with my healthcare provider or doctor if I suspect I have or develop any health issues.
I also understand that I am encouraged by Sam Roze to make health decisions in partnership with my medical providers and to consider the broader role of lifestyle factors such as nutrition, exercise, rest, emotional wellbeing, and stress management alongside breathwork.
By taking part in a session with any of the Releasees, I do so voluntarily and at my own risk. With this understanding, I knowingly and willingly sign this Release and Waiver.
By submitting the below form: I, on behalf of myself, my heirs, and my assigns, hereby release and forever discharge the Releasees from any and all actions, claims, complaints, damages, costs, or expenses of any kind, arising from or connected to any discussions, consultations, or breathwork sessions I have had or may have with the Releasees.