Gut Health Detox Online Retreat                           Thursday 16 - Monday 20 June 2022                               Booking Form & Health Questionnaire
Sign in to Google to save your progress. Learn more
Email *
Name *
Address *
Phone Number *
Date of Birth *
MM
/
DD
/
YYYY
At what level is your yoga practice? *
Required
Do you have experience with fasting/detoxing in the past? *
Required
What is your main reason for joining us on the programme and what goals/outcome are you hoping to achieve from the program? *
Would you describe yourself as being in good health? *
If you answered no please add details
Do you have any health conditions we need to be aware of? (diabetes, cardiovascular including high blood pressure, auto-immune etc.) *
Required
If you answered yes please add details
Are you currently taking any prescription medication? *
Required
If you answered yes please add details
Do you ever lose consciousness or do you lose your balance because of dizziness? *
If you answered yes please add details
Do you have a joint or bone problem that may be made worse by a change in physical activity? *
If you answered yes please add details
Have you had chest pain in the last month when not doing physical activity? *
Required
If you answered yes please add details
Are you pregnant? *
Required
If you answered yes please add details
Do you know of any other reason you should not exercise or participate in a detox retreat? *
Required
If you answered yes please add details
Do you have any food allergies or dietary requirements? *
Required
If you answered yes please add details
How did you hear about this virtual retreat?
I hereby agree to indemnify and hold harmless A Simonsson and L Dunn from and against liability, damages, costs, loss or expense (including without limitation, legal fees) arising out of any bodily injury, at any time sustained by the undersigned. Yoga is no substitute for medical diagnosis and treatment; that yoga practice and/or specific poses are not recommended for individuals with certain conditions (e.g., cardiac illness, early and later stages of pregnancy, post-surgery); and that the student assumes the risk of yoga practice and releases the teacher and studio from any liability claims. I understand that I am here to learn about natural health and better lifestyle practices and that it will be a guide to general health and not medical advise. I understand if I am under the care of a medical doctor I need to have their consent and approval to do this retreat. I understand I should not do a detox if I am pregnant or taking any prescribed medications without consulting with my doctor.   I fully understand that Asa Simonsson and Lisa Dunn are not medical doctors or medical practitioners. I am not here for any medical purposes or treatment procedures.
I agree
Payment Terms & Conditions:  Full payment is £195 and £245 if another person is joining from the same household.  Payment is to be made in full to secure your booking.  For further info or to book, contact Lisa at lisa@lisadunnyoga.com or Åsa at asa@herballinea.co.uk Cancellations:  Whilst we wish to treat cancellations sympathetically, we have decided to keep the places limited so the charge must apply unless you are able to find someone to take your space.
I agree
Payment will confirm your booking and can be done via internet banking. Please transfer funds using the ref - June 2022 Detox: Åsa Simonsson Sort Code: 30-91-59 Account number: 00273764. Or via Lisa's website https://www.lisadunnyoga.com/online/ if you are paying in another currency..
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of lavitainequilibrio.com. Report Abuse
Google Forms