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 Psychiatric Care Severe Mental Illness 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 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 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 4th February 2019 (4 Nights) – Spaces Available Monday 11th March 2019 (4 Nights) – Spaces Available Monday 1st April 2019 (4 Nights) – Spaces Available Waiting list post April 2019 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) Payment Method*We do not accept JCB or American Express. 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 UK Bacs/Bank Transfer International Bank Transfer Gift Voucher – Full or Part Payment Other Method Gender*MaleFemaleDate of Birth* Age*Address Line 1*Address Line 2City, Town or Village*Region/State*Postal Code / Zip Code*Phone Number*Mobile Phone Number*E-mail* Please re type your email address here*Occupation*Marketing Source*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 Queen of Retreats Yovada Yoga Holidays Yoga Travel 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.YesNoI confirm that;* the information I have provided is, to the best of my knowledge true and accurate. I understand that;* any room keys not returned at the end of my retreat will incur a 15 pounds charge per key I understand that;* 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. 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;*The General Data Protection Regulation (GDPR) comes into effect on 25 May 2018, giving each individual more control of his/her personal data. We invite you to exercise your new rights! You can read more about there reform on https://gdpr-info.eu/ I have read and understood Platinum Healing's privacy policy and will inform Platinum Healing if I do not wish to receive any updates or if I do not wish my personal data to be stored. I hereby acknowledge that;* I have agreed to receive all integrated therapies of my own free will and without any coercion or undue influence. I hereby acknowledge that I understand fully* the package that I have chosen and what it involves and includes Signature*Please type your full name below. By contacting us and booking a retreat you have already agreed to our terms and conditions. Date of Signature* Untitled First Choice Second Choice Third Choice
