Standard Cleanse Registration

Ayurveda Cleanse Registration

Cleanse Registration

Name *

Email *

Cell Phone *

Street Address *

City *

State *

Zip Code *

Emergency Contact (Name & Phone) *

Registering for: 12-Day Reboot or 12-Day Ayurveda Fall Cleanse *

Food Reboot ($149)

Traditional Ayurveda Food Cleanse ($149)

What are the top 3 reasons you want to participate in the cleanse? *

Are you being treated by a medical professional for any medical conditions? If so, please explain. *

Do you have allergies or an intolerance to small amounts of dairy in the form of ghee (clarified butter)? *

Have you had your gallbladder removed? *

Do you have high blood pressure? *

If yes, do you currently take high blood pressure medication?

To participate in the cleanse, please fill out the health waiver below. Completed waiver is required for participation in the cleanse. After completing the waiver, navigate back to the cleanse registration form by finding the tab on your internet browser.

Click here to sign the health waiver.

Payment due with registration. *

Zelle - 704-663-9550

Venmo - @Kelley-Gardner-7

Have you signed the cleanse waiver? You are not registered and can not receive access to the cleanse manual, etc. until you sign the waiver. Thank you.

Yes

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