NIRVANA WELLBEING RETREAT

Health / Diet / Treatments
Pre-Retreat Form

Before you attend one of our retreats at Nirvana, it is important that we collect some information about you. Please fill in this form as soon as possible after making a booking.

As always, if you have any questions or concerns, please feel free to contact us via email book@nirvanawellbeingretreat.com.au or phone (07) 5531 0511 (Shanti Yoga Southport Office, Mo - Fri).

    RETREAT DATES:

    FIRST NAME:

    LAST NAME:

    CONTACT PHONE:

    EMAIL:

    ADDRESS (street address, suburb, postcode, state):

    DATE OF BIRTH:

    GENDER:

    OCCUPATION:

    EMERGENCY CONTACT DETAILS

    NAME OF EMERGENCY CONTACT:

    RELATIONSHIP TO EMERGENCY CONTACT:

    EMERGENCY CONTACT NUMBER:

    SPECIAL DIETARY REQUIREMENTS

    Do you have any allergies or food allergies/intolerances? (including gluten / lactose)

    PLEASE LIST ALLERGIES / INTOLERANCES:

    **Please note a surcharge ($25 per day) applies for gluten-free, vegan, and dairy-free options, or if you have any specific allergies that our cook has to cater for.

    YOUR REQUIREMENTS / CONCERNS:

    PLEASE EXPLAIN YOUR HEALTH CONCERNS AND GOALS/REASONS FOR YOUR STAY:

    AYURVEDIC TREATMENTS:
    All Ayurvedic treatments and consultations must be pre-booked. If you would like an Ayurvedic massage or treatment during your stay, please book and prepay here. (Please add dates of your retreat in the notes/message field on checkout.)

    Nirvana Wellbeing Retreat News

    Live well. Get well. Be well. At Nirvana.