| Online Booking Form 2012 |
Please note: This form is for Preconception Fertility Retreats only. Click the following link for the alternative Detox Retreats booking form.
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Note: fields marked with * are mandatory |
* Name: |
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Address: |
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* Home Telephone: |
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Work Telephone: |
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Mobile Telephone: |
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* Email Address: |
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* please repeat Email Address: |
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| ** Please note that each person booking needs to submit a separate booking form and health questionnaire. |
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| Type of accommodation required: |
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Single person own room en-suite £1,445 |
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Single person, own room, shared bathroom with one other £1,245 (CASA MORISCO ONLY) |
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2 people sharing, en-suite bathroom £1,150 (each) |
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Shared wooden chalet with 2 beds and 2 bathrooms en-suite £1,245 (each)
MOINHOS VELHOS only |
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Dates required:
(please note availability information, contact us to confirm if 'limited places remaining' is indicated) |
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2012 |
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January 22th - 29th
2012 |
Casa El Morisco, Spain |
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March 24th - March 31st
2012 |
Cortijo Romero, Spain |
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May 5th - 12th
2012 |
Cortijo Romero, Spain |
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June 23rd - June 30th
2012 |
Cortijo Romero, Spain |
Transformation Detox Retreat
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July 14th - July 21st
2012 |
Mohinos Velhos, Portugal |
Transformation Detox Retreat
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Sept 8th - Sept 15th
2012 |
Cortijo Romero, Spain |
Transformation Detox Retreat
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October 6th - October 13th
2012 |
Mohinos Velhos, Portugal |
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Dec 2nd - Dec 9th
2012 |
Casa El Morisco, Spain |
Please tell us where and when you detoxed previously: |
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Please Note: In the event that your ideal dates are shown as fully booked, you can let us know if you would wish to be placed on a reserve booking list for those dates
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| Detox Programme Health Questionnaire |
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Age: |
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Date of Birth: |
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Weight (kg): |
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Height (m): |
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| Medical History |
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| Are you receiving treatment from a medical doctor? |
| No |
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Yes |
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If yes, for what condition? |
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| Please provide details of medications (names & doses) and details of any abnormal test results you may have had: |
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| Please give details of any other treatments used such as homeopathic remedies, nutritional supplements etc. |
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| 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. |
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| How did you hear about Detox International? |
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| Transfers to and from the airport are INCLUDED in the price. Please let us know your flight details AS SOON AS POSSIBLE so we can arrange suitable pick up times. |
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