Hawaiian Deep Sea Water 10 Day Cleanse

Ten Day Hawaiian Sea Water Cleanse

Makapala Christian Retreat Center

 Kohala, Big Island of Hawaii

Wailana Malie Massage Clinic (808)854-9283

NAME  _____________________________________________________ HM. PHONE___________________

EMAIL (PRINT

CLEARLY)  ________________________________________________ OCCUPATION____________WKPHONE______________________CELL______________________

ADDRESS______________________________________CITY__________________ZIP______________

DATE OF BIRTH____________________HEIGHT__-WEIGHT__

ARE YOU NOW UNDER A DOCTOR'S CARE?  __________

DOCTORS NAME AND PHONE  __________________________

HAVE YOU BEEN DIAGNOSED WITH (HIGH RISK):ACUTE FECAL IMPACTION-__COLITIS DIVE RTICULOSIS-__DIVERTICULITIS__ULCERATIVE COLITIS__ CROHN'S DISEASE- __HYPERIHYPOTHERMIA__ EARLY PREGNANCY (UP TO FOUR MONTHS)__­COLOSTOMY­___

DO YOU HAVE, OR HAVE BEEN DIAGNOISED WITH ANY OF THESE CONDITIONS (CONTRAINDICATONS):

SEVERE HYPERTENSION OR CONGESTIVE HEART FAILURE __ANEURYSM___FISSURES/FISTULAS__

 GI HEMORRHAGE/PERFORATION__BLEEDING HEMORRHOIDS__- ADVANCED PREGNANCY__ CARCINOMA OF THE COLON OR RECTUM__ABDOMINAL HERNIA__RECENT SURGERY__ RECENT RECTAL SURGERY__ RENAL INSUFFICIENCY__

 ARE YOU EXPERIENCING ANY OF THE FOLLOWING CONDITIONS (LOW RISK):

HEADACHES-__DIZZINESS___ BODY ODOR __GAS __DIABETES __ARTHRITIS__FOOD ALLERGY__ CONSTIPATION-__ACID REFLUX- __HEART PROBLEMS__EAR ISSUES__INDIGESTION-__STRESS­__ABDOMINAL PAIN__SLEEP DIFFICULTIES__HIVIAIDS-__ DIARRHEA __FOOD ISSUES­__MARITAL STATUS  _________________________________________________________________________________

DO YOU HAVE CHILDREN?______HOW MANY?____PREGNANT?___ MEDS AND SUPPLEMENTS NOW TAKING_________________________________________________________________________________

 EVER HAD A Colon Cleanse BEFORE?  ___________ If SO. WHEN?  ____________ OTHER DETOX  __________________

HOW MANY BOWEL MOVEMENTS PER DAY DO YOU USUALLY HAVE?  _________________________________________

DO YOU USE LAXATIVES?  ________________ HERBS  _______________ SUPPOSITORY  __________________________

 WHAT WOULD YOU LIKE TO RECEIVE FROM THIS PROGRAM? BE SPECIFIC ABOUT YOUR GOALS?

Release of liability

After reading the details of this program, and confirming it is suited for his/her personal needs,
the undersign hereby releases any and all liability and/or damage incurred during the course of the  10 Day Hawaiian Sea Water Cleanse Program.
Furthermore, the undersigned releases Wesley Sen and Lehua McCandless-Sen, Makapala Retreat Center, their apprentices and/or agents from any and all damage and liability incurred due to negligence or the undersigned and/or of others.
The undersigned hereby agrees and understands the above:
date: ______________________

Signature                                                 Print Name                                                                        Today's Date

_____________________________________________________________________________________________

Cost for 10 day program is $1500.00. $100.00 extra for private room & bath per person (limit 3 rooms, each room sleeps 1 person or a couple). No linens, pillows, and towels provided, self cleaning, coin laundry available, rooms are very rustic basic cabin camp rooms no air conditioning or fans.

For those who desire a B & B quality room we have you stay at http://www.kcadventures.com/ at your own expense plus renting of your own car to travel to and from Makapala to Kapa'au town when the B & B is located. You will pay the program fee of $1500.00 and your lodging at the B & B will be on your own expense.

$1500.00 for 10 day cleanse with no extra charge for separate Men's & Women's dormitory & bathrooms per person. Dorm participants required to provide their own sleeping bag, pillow, towels, and do their own laundry. Fee covers lodging, sea water, perfect 7 formula, vegetarian meals, Hawaiian herbs, infrared sauna, slant board.

All massages are extra and you will pay the therapist directly.

Full body massage sessions are are offered at an extra cost of $60.00 for 60 minutes.

Colon Hydrotherapy sessions $65.00 you will pay the colon therapist direct.  We do not accept payment for massage therapist and colon hydrotherapist.

Note: Airfare and ground transportation not included in fee. You will need to rent a car or take a taxi.

Please email or mail completed form to lomihawaii.com. A deposit with check or money order is due with application. Balance due before start of cleanse, Check, Cash, or Credit card. If you use a credit card you will be charged the service fee that PayPal charges us.

$200.00 Non refundable deposit for Colon Cleanse due with application. Balance of $1300.00 due by January 5,2009 for March 2009 Cleanse .

In the event of an emergency where you cannot attend you may apply the deposit to the next cleanse.

No refunds after 1st day of cleanse.

$200.00 Deposit