Name and Surname*
City
Country
E-mail*
Contact Phone number
Date of Birth
Gender
male female
Check In Date* Check Out Date*
No. of People No. of Rooms 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 1 2 3 4 5 6 7 8 9 10 11 12

Accommodation Type
Family Suite Deluxe Suite Standard Room Occupancy Type*
Single Sharing Programme Name*
Earth Day Retreat 3 day Juicing Detox Start-Up 8 days Yoga Cleansing Program Mediterranean Program Well Balanced Program Do you have any known Medical problems or health concerns?*
yes no
If yes, what is it?

Do you have diabetes?*
yes no
Have you recently undergone any surgery?*
yes no
For women: Are you pregnant?*
yes no
Questions or Comments