Wellness Retreat Booking Form

Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Emergency contact name *

First Name

Last Name

Emergency contact phone *

Country

(###)

###

####

Have you been exposed to hot/cold therapy?

We have a sauna and cold plunge options that we will use. These are optional but there are some contraindications to using them.

Sauna

Cold bath

Both

Do you have any of the following?

Contraindications for cold exposure like an ice bath or cold plunge

Blood vessel problems such as Raynaud’s

Cryoglobulinemia

Paroxysmal cold hemoglobinuria (PCH)

Cold urticaria

Epilepsy

Venous stasis dermatitis

Peripheral Neuropathy

If you have heart, blood pressure or circulatory issues seek medical advice to determine your safety to participate.

None

Do you have any of the following?

Contraindications for hot exposure like a sauna and spa

Low blood pressure or orthostatic hypotension

Dermatitis

Deep vein thrombosis

Chronic heart failure or other heart conditions

Peripheral vascular disease

Pregnant

Diabetes

Sleep hygeine *

Please tick if you're aware of any of the following

I snore

I use a CPAP machine

None of these, that I am aware of

Do you have any of the following? *

Click any that apply.

Vertigo

Epilepsy

Bipolar disroder

Schizophrenia

None

I understand I am responsible for getting myself to and from the retreat. I understand there may be an option to car pool with other guests who are also interested. *

Yes I understand

I understand my investment includes a $500 non refundable deposit for the main house and $1000 non refundable for the villa. If I cannot attend, I forfeit this deposit, unless a full paying replacement guest can take my spot. In which case I will be refunded, less a $55 administration fee. *

Yes I understand and agree to this T+C

I have read the Wellness Retreat brochure including the payment policy, cancellation and refund policy. *

Yes I have

I understand the full balance is payable no later than the 26th September 2024. Failing to pay the balance in full may forfeit my attendance, and loss of investment. *

Yes I understand and agree to this T+C

I understand that I am attending this experience at my own risk and will sign a waiver to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of my participation. *

Yes I understand and agree to this T+C

I understand that photos and videos will be taken and shared by the hosts, Tanya Savva and Vivienne Dias for the purposes of social media, websites and future marketing material. If I do not agree, I will contact them directly to discuss. *

Yes I understand and agree to this T+C