A Consultation A Supervised Fast
Total Days: (if fasting)
First Name:
Last Name
Company Name:
Email:
How you heard:
How I heard about BBDT Flier Friend or Family Internet Meeting or potluck Print Ad Radio Loren Conference, Fair, Festival
Phone (h):
Details about how you heard (friend's name, website address, etc.):
Phone (w):
Phone (mobile):
Fax:
Address 1:
Address 2:
City:
State:
State N/A NSW : New South Wales VIC : Victoria SA : South Australia WA : Western Australia NT : Northern Territory QLD : Queensland ACT : Australian Capitol Territory TAS : Tasmania
Post code
Relationship:
Phone:
E-mail:
Month: January February March April May June July August September October November December Day: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: (e.g. 1976)
Gender:
Male Female
Occupation:
Height:
Weight:
Age:
What is your current diet?
Present Health Problem:
How long has this been a problem?
Surgeries Type(s):
Surgeries Date(s):
List Complications:
Recent hospitalizations:
Present Medications Hormone Treatments Supplements:
Allergies:
Are you pregnant, or think you might be? Yes No
Anaemia/blood disease Arthritis Asthma Back or neck problem Blood in stool Bruise easily Cancer Cardiovascular disease Chronic cough Clot in veins Crohn’s/Colitis Constipation Depression Diabetes Diarrhoea Dizziness, fainting Eating disorder Epilepsy Excessive worry Eye trouble Fatigue Frequent anxiety Gain/loss of weight Gall stones Gallbladder problems Gas or bloating Headache Heart problem
Haemorrhoids Hepatitis Hernia High blood pressure High cholesterol HIV/Aids Hypoglycemia Intestinal problem Jaundice Kidney problem Liver disease Measles Migraine headaches Mononucleosis Multiple Sclerosis Muscle cramps Nervousness Obesity Pain in chest Palpitations Phlebitis Pneumonia Pregnant (currently) Psychiatric problem Pseudoatrophy Rheumatic fever Scar problems Sensitive skin
Sinus/nose problem Shortness of breath Skin problem Sleep problem Stomach problem Swollen glands/lumps Swollen joints Throat problem Thyroid disease Tuberculosis Tumour, Cyst Ulcer Varicose veins Veneral disease Vision problem Men Prostate problem Testicle problem Women Birth control pills Breast problem Excessive flow Irregular periods Pregnancy problems Vagina/uterus problem
Please explain any that you checked above:
Do you smoke? If so, how often?
Do you drink alcohol? If so, how much?
Do you drink coffee? If so, how much?
How much water do you drink a day?
Do you exercise?
Yes No
If so, how often?
Have you ever fasted before?
If yes, was it with water or juice?
List other detox program(s):
Have you been on a weight loss program(s)?
Is there anything else you would like to share?
I have read and agreed to the terms and conditions.
TERMS & CONDITIONS:
Payment & Terms & Conditions: All reservations require a 50% non-refundable deposit by credit card or direct deposit in order to secure your place. The balance must be paid two weeks prior to arrival. If a booking is cancelled a 50% refund of total price is subject to a confirmed re-booking. If a re-booking is unable to be made there will be no refund. The person that made the booking must make cancellations in writing. Prices are subject to change without prior notice, though once a booking is made and secured by a 50% deposit the price will be fixed at the agreed rate. If you decide to leave sooner than planned, we are not able to refund the cost of the remainder of your scheduled time. Byron Bay Detox Retreats reserves the right to amend, vary or cancel any booking. We accept credit card or direct deposit. Once we have received your comprehensive registration form and 50% deposit you will receive your pre-cleanse program and confirmation.
Medical Policy: Byron Bay Detox Retreats is not set up as a 24-hour medical centre; we are not equipped to handle urgent medical care needs, however we do have a doctor on call. We are not a rehab centre for coming off heavy drugs and/or alcohol and are not set up to provide special care for clients who have special physical, physiological or emotional needs. If you are in need of assistance in getting around our property, or other special care, we require you bring someone with you to help meet your special needs. We require that all clients disclose any significant health issues prior to coming to Byron Bay Detox Retreats. Some chronic health conditions may need a doctor’s written letter of approval before commencement.
We would like to take this opportunity to thank you for allowing us to shine some light on your path to health and happiness Awaiting you in good health and an open heart.
