OASIS WELLBEING BOOKING F

BOOKING FORM - WELLBEING OASIS

* Indicates required field

name *

First

Last

Email *

phone Number *

Package *

WILL YOU BE SHARING WITH ANOTHER GUEST *

NAME OF GUEST *

Gender *

Age *

Where are you from? *

Source of referral *

EMERGENCY CONTACT PERSON *

What are your main goals / expectations from this retreat? *

Wellbeing score *

WELLBEING QUIZ

IN ORDER TO CREATE A BESPOKE PROGRAM, WE WOULD LIKE TO KNOW A LITTLE BIT MORE ABOUT YOU. THE MORE INFORMATION YOU CAN GIVE US, THE MORE OUR EXPERIENCED STAFF CAN DEVELOP A PROGRAM AROUND YOUR SPECIFIC NEEDS.

Confidentiality *

AGREE

General Data Protection Policy *

AGREE

PREVIOUS WELLBEING EXPERIENCES *

IF YES, When and for how long? *

Presenting ProblemS / Issues *

Medical history *

Are you currently under the care of a specialist or engaged in any medical treatment programs? *

If Yes, please specify *

HAVE YOU PREVIOUSLY BEEN UNDER THE CARE OF A SPECIALIST OR ENGAGED IN ANY MEDICAL TREATMENT PROGRAMS? *

If Yes, Please specify *

Have you ever had a head injury? *

if yes, please specify *

Are you currently on any Medication *

If Yes, Please specify *

Do you partake in the use of substances? *

If Yes, Please specify (This information is strictly confidential) *

FAMILY MEDICAL HISTORY *

Anything you need us to know to offer you the best possible care and rehabilitation *

THANK YOU FOR YOUR TRUST. BY SUBMITTING THIS INFORMATION YOU ARE EQUIPPING US WITH THE POSSIBILITY OF OFFERING YOU A UNIQUE AND HEALING WELLBEING EXPERIENCE. YOU WILL SOON BE SENT OUR PAYMENT DETAILS. PLEASE NOTE THAT BOOKINGS CAN ONLY BE SECURED ONCE FULL PAYMENT IS RECEIVED.

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BOOKING FORM - WELLBEING OASIS

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