Booking Form First Name*Last Name*Title*MrMrsMissMsDrProfSirDamePre 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) 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 Juice Program*We offer two options of Juice Program on your retreat. Standard Juice Program - 80% Vegetable and 20% Fruit (recommended) Green Juice Program - 100% Green Vegetable Juice (for experienced detoxers only following an alkaline diet) 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! Standard Juice Detox Green Juice Cleanse Self Healing Weight Loss and Fitness Fertility STOP Smoking Inner Child Healing Couples Mens Health Menopause Bridal Detox Preferred Retreat Date (Mid Week 4 Night Sussex Retreats.*PLEASE NOTE: All bookings are subject to availability and only confirmed once we have approved your booking form and payment for the retreat has been received. I'm flexible on retreat dates Monday 14th October 2019 (4 Nights) - Sussex - Fully Booking - Waiting List Only Monday 3rd February 2020 (4 Nights) - Sussex - Limited Availability Monday 16th March 2020 (4 Nights) - Sussex - Limited Availability Monday 13th April 2020 (4 Nights) - Sussex - Limited Availability Monday 11th May 2020 (4 Nights) - Sussex - Availability Monday 1st June 2020 (4 Nights) - Sussex - Availability 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 I will be coming to the retreat:* 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 coming with 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. I'm flexible on occupancy dependent on availability I only want a private room - flexible on which option I only want a sharing room - flexible on which option Deluxe Twin Sharing Room (Single Beds) Superior Twin Sharing Room (King Beds) Master Superior King Room for Couples - En-suite with Shower/WC/Bathtub Deluxe Small Private Room (Double Bed) Separate Private Bathroom with Bath/Shower/WC - For 1 Person only - NO TV/DVD Superior Deluxe King Room - Separate Shared Bathroom with Bath/Shower/WC Superior Deluxe King Room - En-suite with Shower/WC Preferred Payment Option* Already paid for the retreat Pay in full (Full Payment is required if booking within 4 weeks of the retreat start) Pay 50% now to secure your place and 50% 4 weeks prior to retreat start Payment Plan - Pay by small monthly installments (subject to a non refundable deposit to secure your place) Gender*MaleFemaleDate of Birth* Date Format: DD slash MM slash YYYY Age*State/Region*Phone Number*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, Medication, Blood Pressure, History, Diet, Allergies etc.*Emergency Contact Full Name and Number*Aims and Intentions for your retreat*Yoga Level*I confirm that I have read and agree to Platinum Healing's Terms and Conditions and that;* Select All the information I have provided is, to the best of my knowledge true and accurate. Any room keys not returned at the end of my retreat will incur a 15 pounds charge per key any room keys not returned at the end of my retreat will incur a 15 pounds charge per key 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 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. Date of Signature* Date Format: MM slash DD slash YYYY
