5 Elements Registration Application
Thank you for applying for these very special detoxification retreats with Laurel & Andy.

Some of the elements of the retreat have medication & health condition considerations, please fill out each question and if any issues are raised we will get straight back to you.
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Name: *
Your email: *
Please nominate an emergency contact: Name, telephone number and your relationship to this person *
Are you taking any prescription medications or herbal or vitamin supplements? *
Medications & supplement list (if applicable) *
General Health: Please list any health conditions or issues here
Why are you interested in attending this retreat? *
We are offering Purification Sweatlodge (Lakota Native American Style) ceremony(s) as part of this retreat. *
DIET: The 5 Elements retreat is designed as a cellular cleanse based on naturopathic principles. Please nominate the level of dietary detoxification programme that interests you. Note: the final day is a plant-based Phase Out, and we also have specific teas, and other naturopathic/herbal processes throughout the detox. PLEASE CHOOSE THE LEVEL OF YOUR CLEANSE *
All 5 Elements participants will receive a complimentary naturopathic consultation (phone, zoom or in person) prior to the retreat so that every aspect of your health is considered during the retreat. Please tick all that apply to you *
Required
COLONIC HYDROTHERAPY: A safe and efficient treatment to rid the colon of built up wastes and enhances the totality of the cleanse. This retreat requires 2 sessions with option for third (time permitting and at an extra charge). Some health conditions may contraindicate you for this treatment. *
Required
Here's an overview of therapies & group events included in 5 Elements Retreat
Deposit: 50% deposit to required to book your space Cancellation policy: deposit is 100% refundable if your retreat is impacted by Covid-19 restrictions OR if you cancel/change your mind anytime up to 30-days before retreat commencement ONLY, after this date any monies paid become non-refundable if you cancel/change your mind. Final payment due 21-days prior to retreat start date. *
I'm interested in booking in for the following retreat, and will pay my deposit on acceptance: *
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