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?

Payment due with registration. *

Zelle - 704-663-9550

Venmo - @Kelley-Gardner-7

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