| Online Booking Form 2012 |
|
| |
Note: fields marked with * are mandatory |
* Name: |
|
Address: |
|
* Home Telephone: |
|
Work Telephone: |
|
Mobile Telephone: |
|
* Email Address: |
|
* please repeat Email Address: |
|
| |
| ** Please note that each person booking needs to submit a separate booking form and health questionnaire. |
| |
| Type of accommodation required: |
|
2 people sharing a room with twin beds and an en-suite bathroom R16622.21 per person for the week. Fordoun hotel and spa. Sharing is only available to people who already know each other e.g. friends, partners, family, etc. |
|
2 people sharing a room with a double bed and an en-suite bathroom R16622.21 per person for the week. Fordoun hotel and spa |
|
1 person in a luxury large single room with an en-suite bathroom R18677.21 per person for the week. Fordoun hotel and spa |
|
2 people sharing a room with a double bed and an en-suite bathroom R15307.50 per person for the week. Temenos |
|
1 person in a single room with an en-suite bathroom R15762.50 per person for the week. Temenos |
| |
Dates required:
(please note availability information, contact us to confirm if 'limited places remaining' is indicated) |
| |
2011 |
|
|
October 7th - 14th
2011 |
Temenos,
McGregor |
|
November 20th - 27th
2011 |
Fordoun Spa,
Midland Meander
FULLY BOOKED |
| |
|
|
| |
2012 |
|
|
February 10th - 17th
2012 |
Temenos,
McGregor |
|
May 28th - June 3rd
2012 |
Fordoun Spa,
Midland Meander |
Please Note: In the event that your ideal date isshown as fully booked, you can let us know if you would wish to be placed on a reserve booking list for the next retreat.
|
On reserve list: |
Yes
|
|
No |
|
|
Detox Programme Health Questionnaire |
|
Age: |
|
Date of Birth: |
|
Weight (kg): |
|
|
Height (m): |
|
| |
|
| Medical History |
|
| Are you receiving treatment from a GP? |
| No |
|
Yes |
|
If yes, for what condition? |
|
|
| Please provide details of medications (names & doses) and details of any abnormal test results you may have had: |
|
|
| Please give details of any other treatments used such as homeopathic remedies, nutritional supplements etc. |
|
|
| |
| Health Profile |
| Please make a list of all the health problems that you would like to clear up and indicate how long you have had these problems (eg. headaches - 7 years). Please start at number 1 with the problem of the longest duration, ending with the problem that occurred most recently. |
| 1.
|
|
| 2.
|
| 3.
|
| 4.
|
| 5.
|
| 6.
|
| 7.
|
| |
Click here if you would like to receive our
FREE QUARTERLY NEWSLETTER |
|
| |
| How did you hear about Detox International? |
|
|
| |
|
|
|
|
| |
|
