Booking Form First Name*Last Name*Title*MrMrsMissMsDrProfSirDameDelivery Address*Please provide address for the delivery of your home detox box, if you are joining a home detox retreat. If not, just simply provide your home address. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Pre Screening*Please note that Platinum Healing is NOT a medical or a mental health facility. If ANY of the following apply to you, please DO NOT complete this form. You can contact us . Pregnant or Nursing Mother, Insulin Dependent Diabetes, Peptic Ulsers, Cardiac Arrhythmia, Tuberculosis, Advanced Heart Disease, receiving any form of Psychiatric Care, Severe Mental Illness, Alcoholism, Drug Abuse or Addiction, Anorexia or extremely underweight. NONE OF THE ABOVE APPLY TO ME (Please continue with this booking form) Home Detox Juice DeliveryOur juice partner is NOT able to supply juices for anyone with nut or other allergies that result in anaphylactic shock. They produce nut milks and use celery in their juices. I do not have allergies that result in anaphylactic shock Have you already been in contact with us?* Yes No A long time ago I have already booked the retreat I just need to complete my form I am a returning guest Preferred Program* Home Detox, Yoga and Healing - with juice delivery Home Detox, Yoga and Healing - without juice delivery Standard Juice Program - 80% Vegetable and 20% Fruit (recommended) Green Juice Program - 100% Green Vegetable Juice (for experienced detoxers only following an alkaline diet) Self Catering Wellness Break (Kitchen Required) Preferred Retreat Program (please note that ALL retreat programs run simultaneously together and the only difference is the treatments that are included in each package)*If you are coming to quit smoking, for fertility, menopause etc.. please note that NOT everyone is coming for these reasons. The retreats are mixed with different requirements and are also mixed gender. I'm not sure please HELP! Home Detox Program Standard Juice Detox Green Juice Cleanse Self Healing Weight Loss and Fitness Fertility STOP Smoking Inner Child Healing Couples Mens Health Menopause Bridal Detox Self Catering Wellness Holiday Preferred Retreat Date*PLEASE NOTE: All bookings are subject to availability and only confirmed once we have approved your booking form and full payment for the retreat has been received. I'm flexible on retreat dates Home Detox Program - Starts every Friday morning Monday 13th July 2020 (4 Nights) - Sussex - Availability Monday 10th August 2020 (4 Nights) - Sussex - Availability Monday 14th September 2020 (4 Nights) - Sussex - Availability Monday 12th October 2020 (4 Nights) - Sussex - Availability Waiting List for Belvoir Castle Retreat - Leicestershire Waiting List for 2021 Home DetoxPlease specify the date you would like to join. Home retreats start every Friday morning. Please also specify the duration. We offer 3, 5, 7, 14 and 28 days. I will be:* detoxing with you at home coming alone with a friend (please provide full name and relationship below) with a family member (please provide full name and relation below) with my partner (please provide full name below) in a group (please provide full names of your entire party below) Who is joining you?Names and relationship to the people I am coming to the retreat with (if applicable). PLEASE NOTE: All individuals joining you MUST complete a separate booking form. We cannot accept a joint booking form. Preferred Occupancy*Occupancy is subject to availability. At home supported detox I'm flexible on occupancy dependent on availability I only want a private room I only want a sharing room (only available if coming with someone) Couples Room for 2 People Low Budget Accommodation Deluxe Accommodation Superior Accommodation Self Catering Option with Kitchen Twin Room - Belvoir Castle Single Room - Belvoir Castle Couples Room - Belvoir Castle Preferred Payment Option* Already paid for the retreat Pay in full (Full Payment is required if booking within 90 days of the retreat start) Pay 50% now to secure your place and 50% 90 days prior to retreat start Payment Plan - Pay by small monthly instalments (subject to a non refundable deposit to secure your place) Gender*MaleFemaleDate of Birth* Date Format: DD slash MM slash YYYY Age*Mobile Phone Number*Email* Occupation*How did you hear about us?*Have you ever been on a detox retreat before?*YesNONo - but I have been on a wellness or yoga retreat beforeIf yes please give the name and locationWhat made you choose Platinum Healing over other Retreats?*Health Concerns, Injuries, Medication, Blood Pressure, History, Diet, Allergies etc.*Emergency Contact Full*Emergency Contact Number*Aims and Intentions for your retreat*Yoga Level*I confirm that I have read and agree to the Terms and Conditions and that;* Select All the information I have provided is, to the best of my knowledge true and accurate. I have travel insurance in the event of ANY cancellation or travel restrictions I do not have allergies that result in anaphylactic shock any room keys not returned at the end of my retreat will incur a £40 charge per key to replace there is a set juice detox menu included in the price of the retreat. Everything on our menu is natural, vegan, gluten, wheat and dairy free. Please inform us if you have any specific requirements, food preferences, intolerances or allergies. If we are required to alter the program or create a tailored menu, a surcharge will apply. my GP/Medical Practitioner and I remain responsible for my own health throughout the retreat and beyond. Platinum Healing is a retreat for 'Self Healing' NOT a medical, mental health, addiction or drug/alcohol rehab facility. I assume full responsibility for obtaining clearance from my medical practitioner to attend a retreat or participate in any retreat activity. I have agreed to receive all integrated therapies of my own free will and without any coercion or undue influence. In understand the package that I have chosen and what it involves and includes I agree to all booking and cancellation terms I hereby acknowledge that;* I have read and understood Platinum Healing's privacy policy and I am happy for Platinum Healing to contact me and for my personal data to be stored. Signature*Please type your full name below. By contacting us and booking a retreat I have already agreed to the terms and conditions and understand the cancellation policy. Date of Signature* Date Format: MM slash DD slash YYYY Payment*I have already paidI need to pay
