7 DAY FASTING AS A PATH OF DHARMA RETREAT Inquiry Form

7-Day Fasting as a Path of Dharma Retreat Inquiry Form

Detox Retreat Calendar 2017

First Name *

Last Name *

Gender *

Email *

Mobile Phone Number/Whatsapp *

Please include your international country code

Date of Birth *

Nationality*

OTHER INFO:

PLEASE NOTE THIS INFORMATION IS KEPT CONFIDENTIAL!!!!

Emergency Contact - Name & Phone number *

Have you joined a detox or cleansing program before or is this your first time?

What are the main reason(s) you are joining us, and what do you hope to achieve? *

Have you had previous or currently, any of the following health conditions? *

Pregnant or Breast Feeding (Now)
Diabetes
Blood Sugar Imbalance
Colon Disease
Heart Disease
Eating Disorder (e.g. Bulimia, Anorexia)
Depression

Anxiety
Mental Illness
Alcoholism
Drug Abuse
None of the above
Other

Please select all that apply.

Other health condition

Have you been diagnosed with any other medical/health condition that may be of relevance to your detox experience? Please list ANYTHING that concerns you:

Are you currently taking any prescribed medication and/or natural supplements? If YES please list the names and dosage.*

Do you have any known allergies or intolerances? If Yes, please provide more details.*

Any other Comments or Special Needs?

Terms and Conditions *

I accept the terms and conditions. This is important! Please make certain you read our Term & Conditions

7-Day Fasting as a Path of Dharma Retreat Inquiry Form

Detox Retreat Calendar 2017

Payment