First Name *

Last Name *

Email *

Arrival Date

Returning guest?

Height

Relationship status

Age

Current Weight

Emergency Contact *

Name, Contact Details, Country of Residence

What is the main reason for coming to Orion Healing?

Have you ever been hospitalised?

If yes, please provide details

Have you detoxed before?

If yes, when and where was your experience?

Please list your main health concerns

If yes, please list these below

Have you had any abdominal surgery/Colonoscopy in the past 12 months?

If yes, please provide details:

What role does sports and exercise play in your life?

How many times/day/week do you have bowel movement?

Please list your general breakfast choices

Please list your general lunch choices

Please list your general dinner choices

Please list your general snack and drink choices

Is your cycle regular?

Have you had any dental work: filling, crowns, implants?

If Yes, please provide more information:

What do you do to balance stress?

What is your Current Emotional State?

brief overview, e.g. optimistic, angry, sad, happy, anxious, resentful, jealous, worried, positive etc.

What is the the most important thing you wish to change about your diet to improve your health?

How do you want to feel on a daily basis?

Anything else you want to share?

Disclaimer *

I confirm that I have read the Orion Healing Centre Terms and Conditions & Program Disclaimer Waiver and agree to all conditions set forth without exception. I also confirm that the information I have provided is correct to the best of my knowledge. By ticking the confirm box, I am agreeing to the equivalent of an electronic signature stating that I am in full agreement with all Orion Healing Centre terms and conditions.