Health Questionnaire and Pre-Reservation Form
PERSONAL DETAILS * Denotes mandatory fields.
Choose from the list the diseases that you have already had or are predisposed to:
(This health questionnaire should be filled out in collaboration with
Do you have previous experience
of fasting? If so, please give us some feedback of your experience,
we especially interested in how long you fasted (1 day, 3
days, week etc.) How regularly (every month, twice a year,
only once etc.) Wheather you found it easy or difficlut, and
what benefits or problems you found.
Location:
Hungary
Croatia
Cyprus
France
Type the date when you will arrive
(we are open the whole year)
Check-in date: (dd/mm/yy)
Check-out date: (dd/mm/yy)
Choose the number of days you
will stay with us:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
What type of accommodation
and services do you require?*
Want to know more about program options? Go here
We will confirm the booking
by sending you a fax or an e-mail message.
Additional comments, special
requirements:
How did you find out about our
anti-aging program?
Your Certification Is Required to Process this Form:Terms and Conditions for my Anti-Aging Detox Program I am ordering now.
Security code:
