Mudita Cleanse Booking Form
Welcome to our Residential Cleanses Booking Form! Please note that the fields marked with a red star are compulsory. If you have any problems at all with the form, please call us on (02) 6684 6090.
Once you have completed the form you will be taken to our PAYPAL website where you can pay the $300 non-refundable deposit securely online. If you'd rather pay in another way please just cancel the paypal payment and give us a call on 02 6684 6090.
MOBILE PHONE (or home phone if you don't have a mobile):
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Democratic Republic of the Congo
Republic of the Congo
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
United States Minor Outlying Islands
Virgin Islands, British
Virgin Islands, U.S.
DATE OF BIRTH:
EMERGENCY CONTACT. Please provide the name and mobile/home number of a person to contact in case of an emergency:
LENGTH OF CLEANSE: Please let us know the length of the cleanse you'd like to do:
REQUESTED DATES: Please let us know what dates you'd like to do your Cleanse (this will be subject to availability)?
ACCOMMODATION: Will be staying at the clinic (if not, you can deduct $100 per night for accommodation from the total cost)?
ACCOMMODATION: If staying at the clinic, would you like to stay additional nights before or after the cleanse (cost $100 per night)? If yes, how many nights?
CATERING: Please let us know if you would like to be catered for ($60 per day extra). Partial catering may also be an option (i.e. you cook 1-2 meals and we provide others):
If you've chosen Partial Catering, let us know what you'd like (e.g. lunch, dinner or breaky, lunch etc)
ADDITIONAL ACTIVITIES: Please let us know if you are interested in any of the following additional consultations and activities (subject to availability):
Ayurvedic Cooking Class
Restorative Yoga/Yoga Nidra Class
PREVIOUS AYURVEDIC CLEANSING EXPERIENCE: Have you carried out an Ayurvedic Cleanse or Panchakarma before? If yes, please provide details.
EXISTING EXPERIENCE WITH AYURVEDA: Do you have existing experience in Ayurvedic diet and lifestyle approaches and are you familiar with Ayurvedic cooking?
HEALTH CONCERNS OR INJURIES: Please outline any health concerns, injuries or psychological issues that we should be aware of.
EXPECTATIONS: Please let us know what you'd most like to get out of your cleanse.
HOW YOU FOUND US: Please let us know how you found out about our Cleanses (if a friend recommended it, please let us know who so we can thank them) x
**** PLEASE READ CAREFULLY ****
1) I acknowledge and agree upon the following payment and cancellation terms and conditions:
To reserve my booking for a Mudita Cleansing Program, I will need to make a $300 deposit. The deposit is non-refundable – however should I cancel my reservation 30 days or more before the start of the cleanse, I may apply my deposit towards another Mudita Cleanse within 6 months.
I have read and accept the Terms and Conditions outlined above.
Do Not Fill This Out