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| What program are you inquiring about? | |||||||||||||
| Select session dates | |||||||||||||
| Number of people attending | |||||||||||||
| Room type | What health issues are you currently facing? |
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| What do you most hope to gain from attending a wellness program at the Health Retreat & Spa? |
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| How did you hear about us?: | |||||||||||||
| How eager are you to invest in a health retreat that transforms your health (and changes your life) in just 10-14 days? * |
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| First Name | ||
| Last Name | ||
| Please send my brochure by* | ||
| Mailing Address | ||
| City | ||
| Province\State | ||
| Zip/Postal Code | ||
| Country | ||
| Confirm Email | ||
| Phone (work) | ||
| Phone (home) | ||
| Mobile Phone | ||
| Best time to reach you. | ||
| Brochure code. | ||
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| Do you have any diagnosed or undiagnosed conditions with: | |
| Colon (Colitis, Chrone's, No Colon) |
Yes No |
| Describe: | |
| Liver (Jaundice, Gallbladder Stones, Hepatitis,Cirrhosis) |
Yes No |
| Describe: | |
| Kidneys (Stones, Insufficiency, Failure) |
Yes No |
| Describe: | |
| Are you currently under physicians care for cardiac condition (stroke, heart attack, HPB 200/100 and higher, pacemaker)? | |
| Did you have a stroke/heart attack in the past 6 months? | |
| Have you been diagnosed with an infectious disease in the last 6 months? | |
| Has your gallbladder been removed? | |
| Have you had any surgeries in the past 6 months? | |
| Details | |
| Have you been within the past 6 months under the care of a psychologist or psychiatrist? | |
| Are you currently dealing with cancer? | |
| Are you currently experiencing Bleeding/Blood Clotting Problems | |
| Do you/did you have Hepatitis? | |
| What type and year you had it? | |
| Do you/did you have Epilepsy? | |
| Do you/did you have Tuberculosis? | |
| Do you/did you have HIV (AIDS)? | |
| Do you smoke? | |
| Do you use: | |
| Recreational drugs? | |
| How often? | |
| Alcohol? | |
| How often? | |
| Are you/might be pregnant? | |
| Do you need assistance to go up and down the stairs? | |
| Allergies/food sensitivities | |
| Substances that provoke the reaction | |
| Severe reaction? | |
| Snoring /Sleep apnea? | |
| Do you require any other special assistance due to health condition? | |
| Do you clearly understand that we are not a "lush-posh" spa, clinical depression recovery or a medical centre and the primary reason why people come here is to begin improving their well being through natural means using Advanced Whole Body Detoxification and/or Juice Fasting? | Are you comfortable to be in a group environment of people with different personalities, health conditions, and social, professional, national and religious backgrounds that have come to detoxify and improve their health, just like you? |
| Do you clearly understand that it is a Supervised, Structured program, where the Detox portion of it is not an option, for safety reasons? | |
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