Name *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reasons for choosing Escapada Health *

Healthy holiday

Change of lifestyle

Symptom management

Stress relief

Recommendation

Other (please state)

Medical History

Gender

Male

Female

Date of Birth *

MM

DD

YYYY

Past or Current Medical Problems *

Allergies

Arthritis

Bowel or Bladder Problems

Cancer

Heart/ Blood Pressure Problems/ Angina

Diabetes

Digestive complaints

Hearing impairments

Lower back pain

Back/Neck problems

Neurological conditions

Osteoporosis

Prolapse disc in the spine / sciatica

Lung conditions

Circulatory conditions of disease

Vision impairment

Pressure in eyes or detached retina

None of the above

Any other health concerns that may be relevant? *

Yes

No

Any recent surgeries *

Yes

No

Are you taking any medication (or have in the last six months)? *

Yes

No

Are/could you be pregnant now or have you had a baby in the last 12 months? *

Yes

No

Do you have any food allergies/intolerances/preferances *

Yes

No

Level of Yoga/ Qi Gong practice

Beginner

Intermediate

Advanced

Pre Retreat Call

Would you like to arrange a pre retreat chat with your designated retreat team member?

Yes

No thanks

Health & Wellness Treatments

Are you interested in further health and wellness offerings during your stay with us? A brochure will be sent to you over the next few days

Body Acupuncture

Rejuvenating Facial Acupuncture

Needle Free Hayo’u Guasha Facial

Detoxing Body Guasha & Cupping Massage

Wellness Massage

Pedicure or Manicure

Liability Disclaimer & Notice * *

I will consult a physician prior to enrolling to practise yoga/ qi gong. Otherwise I assume the physical risk of my own physical condition, past and current medical issues/injuries/illness or medication that may affect me on this retreat. I understand that mindful movement is not a substitute for medical attention, examination, diagnosis, or treatment. I recognise that it is my responsibility to notify my teacher of any serious illness or injury before every movement session. I will not perform any postures to the extent of strain or pain. if at any time during the class, you feel discomfort or strain, gently come out of the posture. I accept that neither the teachers, personnel, nor Escapada and its owners, are liable for any injury, or damages, to person or property, resulting from taking the class or in the future and I use the premises at my own risk.

I agree

Booking Terms and Conditions *

I agree to Escapada's Booking Terms and Conditions. Please see website for full Terms & Conditions.

I agree