Booking Form First Name*Surname*Title*MrMrsMissMsDrProfSirDamePre Screening Questions. If any apply to you DO NOT complete the form. Please contact us.*Please note that Platinum Healing is NOT a medical or a mental health facility. NONE OF THE BELOW APPLY TO ME (Please continue with this booking form) Pregnant or Nursing Mother Insulin Dependent Diabetes Peptic Ulsers Cardiac Arrhythmia Tuberculosis Advanced Heart Disease Receiving Psychiatric Care Severe Mental Illness Underweight 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 If you are a returning guest please confirm the month and year that you completed your last Platinum Healing Retreat?The Platinum Healing Team are looking forward to supporting you through another healing journey and thank you for considering us again. Please don't forget to ask us about our returning guest special offers.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 (No Treatments Included) Green Juice Cleanse (No Treatments Included) Self Healing (Includes 1x Naturopathy or Herbal Medicine, 1 x Hypnotherapy, 1x Acupuncture or Reflexology) Weight Loss and Fitness (Includes 1x Fitness Training, 1x Naturopathy or Herbal Medicine, 1x Hypnotherapy and Enema Package) Fertility (Includes 1x Naturopathy or Herbal Medicine, 1x Hypnotherapy, 1x Acupuncture or Reflexology) STOP Smoking (Includes 2 x Smoking Cessation Hypnotherapy Sessions) Inner Child Healing (Includes 2 x Inner Child Healing Sessions) Couples (Optional Relationship Counselling or Treatments at an additional cost) Mens Health (Includes 1x Naturopathy or Herbal Medicine) Menopause (Includes 1x Naturopathy or Herbal Medicine, 1x Hypnotherapy, 1x Acupuncture or Reflexology) Bridal Detox (Tailored Program) Preferred Retreat Date (Mid Week 4 Night Sussex and Lincolnshire 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 August 2017 (4 Nights) - Sussex - WAITING LIST ONLY Monday 18th September 2017 (4 Nights) - Sussex Monday 9th October 2017 (4 Nights) - Sussex Monday 30th October 2017 (4 Nights) - Sussex 2018 Waiting List Lincolnshire Waiting List 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) 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 Large Sharing Female Quad Room (Single Beds) Separate Shared Bathroom with Shower/WC - Lincolnshire Only Triple Sharing Room (Small Single Bed) - En-Suite Shower/WC - Sussex Only Triple Sharing Room (King Bed) - En-Suite Shower/WC - Sussex Only Standard Twin Sharing Room (Single Beds) - Separate Shared Bathroom with Bath/Shower/WC - Sussex Only Standard Twin Sharing Room (Single Beds) - En-Suite Shower/WC Deluxe Twin Sharing (Single Beds) - En-Suite Bath/Shower/WC - Sussex Only Very Small Private Room (Double Bed) Separate Private Bathroom with Bath/Shower/WC - For 1 Person only - NO TV/DVD - Sussex Only Deluxe Private Room (King Bed) Separate Shared Bathroom with Bath/Shower/WC - Sussex Only Super Deluxe Private Room (King Bed) En-suite with Shower/WC Super Deluxe Couples Room (King Bed) En-suite with Bath/Shower/WC - For 2 persons Superior Deluxe Couples Room (Super King Bed) En-suite with Shower/WC and Roll Top Bath Tub in Bedroom - For 2 persons - Lincolnshire Only Private Cottage (Lincolnshire Only) 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 50% deposit to secure your place) Payment Method*If you have not already made payment we will contact you once we have reviewed your booking form. I have already paid UK Debit Card Credit Card inside the EU (3% Charge) Credit Card outside the EU (4% Charge) International Debit Card (4% Charge) International Credit Card (4% Charge) UK Bacs/Bank Transfer International Bank Transfer Gift Voucher – Full or Part Payment JCB or American Express (sorry we DO NOT accept) Other Method Gender*MaleFemaleDate of Birth* Age*Address Line 1*Address Line 2City, Town or Village*County / State / Province*Postal Code / Zip Code*Home Telephone Number*Mobile Number*Personal E-mail* Please re type your email address here*Work or other email Occupation*How did you hear about Platinum Healing?* I am coming with a friend/family member who found you Referred by previous retreat guest Internet Search Engine (google, yahoo, bing etc) The Retreat Company Neals Yard Holidays Queen of Retreats Book Yoga Retreats Travel Quest Printed Magazine Digital Magazine Telegraph The Observer Blog Facebook Twitter Instagram Show/Exhibition Other If you found us by searching online what were the keywords you used?If you found us in a magazine, newspaper, online article or blog please confirm which oneIf you were refered by a friend, previous retreat guest or member of our team please provide full nameHave 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?*Car Parking Require?*Free parking is available for the duration of the retreat. Please kindly park very closely to other guest vehicles in the car park to ensure that there is enough space for everyone. Many thanks in advance.YesNoCar Registration (if driving to the retreat)I confirm that;* the information I have provided is, to the best of my knowledge true and accurate. I confirm that;* I have read, understood and agree to the Platinum Healing Ltd Terms and Conditions I understand that;* my GP/Medical Practitioner and I remain responsible for my own health throughout the retreat and beyond. I understand that;* Platinum Healing is a retreat for 'Self Healing' NOT a medical, mental health, addiction or drug/alcohol rehab facility. I agree NOT;* to attend a retreat or participate in any retreat activity including classes and treatments if I have not received clearance from my GP/Personal Physician and I assume full responsibility for obtaining such clearance. I consent to;* treatment involving the application of all integrated therapies and treatments on the retreat. I hereby acknowledge that;* I have agreed to receive all integrated therapies of my own free will and without any coercion or undue influence. Signature (please type your full name below) to agree to all terms and conditions*Date of Signature*
