7 DAY DETOX RETREAT BOOKING FORM – JANUARY 2025 Date of Detox 12th - 19th January 2025 Personal Info GenderMaleFemalePrefer not to say NationalityAfghanAlbanianAlgerianAmericanAmerican SamoanAndorranAngolanAnguillanAntarcticAntiguan And BarbudanArgentineArmenianArubanAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianBosnian And HerzegovinianBotswanan (Motswana)Bouvet IslanderBrazilianBritishBritish Indian Ocean TerritoryBruneianBissau-GuineanBulgarianBurkinabeBurundianBurmeseCambodianCameroonianCape VerdeanCaymanianCentral AfricanChadianChileanChineseChristmas IslanderCocos IslanderColombianComoranCongoleseCongolese (DRC)Cook IslanderCosta RicanCroatianCubanCypriotCzechDanishDjiboutianDominicanDutchDutch AntilleanEcuadorianEgyptianEquatorial GuineanEritreanEmiratiEstonianEthiopianFalkland IslanderFaroeseFijianFilipinoFinnishFrenchFrench, MetropolitanFrench GuianeseFrench PolynesianFrench Southern TerritoriesGaboneseGambianGeorgianGermanGhanaianGibraltarGreekGreenlandicGrenadianGuadeloupeanGuamanianGuatemalanGuineanGuyaneseHaitianHeard And McDonald IslandsHonduranHong KongeseHungarianI-KiribatiIcelanderIvorian (Côte d'Ivoire)IndianIndonesianIranianIraqiIrishIsraeliItalianJamaicanJapaneseJordanianKazakhstaniKenyanKittian And NevisianKuwaitiKyrgyzstaniLaotianLatvianLebaneseLiberianLibyanLiechtensteinerLithuanianLuxembourgishMacaneseMacedonianMalagasyMalawianMalaysianMaldivianMalianMalteseMarshalleseMartinicanMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMontserratianMoroccanMosotho (Basotho)MozambicanNamibianNauruanNepaliNew CaledonianNew ZealanderNi-VanuatuNicaraguanNigerienNigerianNiueanNorfolk IslanderNorth KoreanNorthern Mariana IslanderNorwegianOmaniPakistaniPalauanPanamanianPapua New GuineanParaguayanPeruvianPitcairn IslanderPolishPortuguesePuerto RicanQatariReunioneseRomanianRussianRwandanSahrawiSaint HelenianSaint-Pierrais And MiquelonnaisSaint LucianSamoanSammarineseSao TomeanSaudi ArabianSenegaleseSeychelloisSierra LeoneanSingaporeanSlovakSlovenianSolomon IslanderSomaliSouth AfricanSouth Georgian And South Sandwich IslanderSouth KoreanSpanishSri LankanSudaneseSurinamerSvalbard And Jan Mayen IslanderSalvadoranSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTimoreseTogoleseTokelauanTonganTrinidadianTunisianTurkishTurkmenTurks And Caicos IslanderTuvaluanUgandanUkrainianUnited States Minor Outlying IslanderUruguayanUzbekistaniVatican City ResidentVenezuelanVietnameseVirgin Islander (British)Virgin Islander (U.S.)VincentianWallisian And FutunanYemeniYugoslavZambianZimbabwean Date of Birth Contact Info *Please include country code Have you had previous or currently, any of the following health conditions? Please select all that apply Pregnant or Breast Feeding (Now)DiabetesMental IllnessColon DiseaseHeart DiseaseEating Disorder (eg. Bulimia, Anorexia)None of the aboveAnxietyBlood Sugar ImbalanceAlcoholismDrug AbuseDepressionOthers How did you hear about us? SelectReferral from Friend/FamilyInternet SearchI’m a Returning GuestSocial MediaAdvert / FlyerMagazine ArticleWebsite / BlogOther I accept the Terms & Conditions.
