Pancha Karma Registration Application
Get on the waiting list for your 2024 Cleansing and Rejuvenation Program
*Please note:  Registration application needs to be accepted before you make your travel arrangements. Your dates are not secure until deposit is received. Deposit WILL BE REFUNDED to you if your application is not accepted at this time.

This is your registration application please complete this form and send it in with deposit

Sign in to Google to save your progress. Learn more
Email *
Print Full Name: *
Phone *
Please tell me about why you are wanting Pancha Karma at this time. *
Ultimately how many days of Pancha Karma would you like? *
We will open up dates soon please indicate month of your proposed date range for receiving Pancha Karma: (Please give the widest range possible) *
Have you received the Covid Vaccine? (It is not a requirement.) *
If you received the vaccine, how many and when? *
My intentions for receiving Pancha Karma are: *
Birth data: 00/00/00 time 00:00 (Accuracy here is important) Location: (city/state) where you were born *
Check off conditions that you have now or have had *
Required
Anything else not listed? *
Please list medications/vitamins/herbs are you currently taking: *
Please document a history of any health concerns, surgeries, illnesses, healing crises *
Your current self-care program, i.e., yoga 3x per week etc. *
Anything else you would like me to know? *
Appointment Policy: Verbal reservations are made, and a deposit must be received within 24 hours. If your deposit is not received within that time your dates may be given to someone else. Please make sure that we receive your deposit before making airline reservations. Rates are subject to change. A non-refundable 50% deposit is required to reserve your time and space. The balance is due on your first day of your Pancha Karma program. We accept, Mastercard and Visa, and cash. Please understand that if you are late or don’t show for your scheduled treatments, you miss out on that time. *
I understand that Pancha Karma is not to be used in place of medical treatment, and that I should check with my doctor before making any changes to my diet or lifestyle. Pancha Karma is a program consisting of massages, and steam treatments and not a medical treatment for any medical condition. I agree to hold harmless, Darci Frankel, Hanalei Day Spa, Shanti Enterprises Inc., or any affiliated organization from any claims any heirs or I may make. By signing below, I agree that I am completely responsible for my physical, psychological health and well-being. This agreement is legal and binding. Print full name here means I agree to all the above. *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy