Panchakarma or Private Cleansing Registration Form

First name

Last name

Gender

Date of birth

Address

Phone Number

I confirm I am registering for:

Panchakarma or Private Cleansing

How did you learn of us?

Why are you registering for a panchakarma or private cleanse?

If you selected other in the question above, please describe.

Do you have any dietary restrictions or allergies?

Describe your experience with yoga asanas (poses), pranayama (breathing techniques), meditation.

Please share your experience with Ayurveda. How familiar are you, have you been through any type of Ayurveda cleanse in the past?

What do you hope to achieve through the cleanse?

Do you have any questions you'd like to discuss about the cleanse?

I acknoweldge and agree that no refunds are provided after payment is made, for any reason. If cancelled at least 48 hours before program begins, payment will transfer to credit with Illumine Ayurveda & Yoga that can be used within 1 year of payment date. Cancellations less than 48 hours before the start of the program or initial consultation are not eligible for refunds or credit.

I am ready to send my $250 deposit and consultation fee. Please send me payment details and scheduling link and we'll talk about total program length and final payment then.

I would like to schedule a Clarity Call to discuss questions I have. Please send me a link to schedule a call.

I would like to subscribe to the mailing list. Please add me.