Hanalei Day Spa & The Ayurveda Center of Hawaii
Registration Application

Important Information about the Registration Application:

• Cut and paste the application below directly to your email.

• 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. 

• Please complete this form and send it in with two current photos; close up of face and clothed full body.

• Take as much space as you need to.

• This information is confidential.

Full Name:
Birth data:    /   /    time   :   (Accuracy is important here, for Vedic astrology)
Location: (city/state) where you were born
Home Address:
Home Phone:                         Cell Phone:
E Mail:                                   Work:
Yes, I want to attend _______________________ retreat, a 50% deposit is required to register.
Proposed Dates for _______________________ retreat or Pancha Karma:    
From     /   /___    to       /   /___    
Please charge my (Master or Visa) (card number) ___________________ Expiration date___________
CVV2 code (last 3 digits on the he back of card) ________   Billing address____________________________________________
My intentions for receiving Pancha Karma are: 

Underline any of the following conditions that you have now or have had and include dates:
athletes foot (needs to be cleared up before treatment, ask for remedy if you do not already have one), pregnancy, lactation, hypertension, lympho-sarcoma, cancer of the lungs or testicles, melanoma, congestive heart failure, HIV or AIDS, dehydration, or any active infectious disease please explain.

Asthma, allergies, emphysema, chronic fatigue syndrome, carpal tunnel syndrome, fibromialgia, obesity, cigarette smoking current/past, Chron's syndrome, irritable bowel syndrome, stomach ulcer, shingles, herpes simples/genitalis/zoster (shingles), food addictions, substance abuse. Other________________________________________
(This information is confidential.)  Please document your recreational drug/substance use of past, present and future.
Below, please describe your state of health, current medical treatments, health concerns, illnesses, healing crises prescription drugs, list vitamins/herbs, and history of any surgery:

Please document any allergies and/or food allergies, also, are you allergic to oils? If so which one(s)?:

Appointment Policy: Please make sure that we receive your deposit before making airline reservations. Rates are subject to change.
A 50% deposit is required to reserve your time and space. The balance is due on day one of your retreat or Pancha Karma program. We accept master, visa, discover and cash. If you would like a receipt, please ask. The deposit is non-refundable yet may be transferable under certain conditions. 
Client Responsibility (For Pancha Karma): This is a time to be inward, a time to rest, recharge and become aware of your inner world.  It should be introspective and enjoy your Pancha Karma. If you are late or don’t show for your scheduled treatments then you miss out on that day of treatments. If you do not follow instructions, or use recreational drugs during your Pancha Karma program this may result in the termination of your Pancha Karma treatment and you may not receive a refund.  It is the responsibility of the client to follow these guidelines and also report any concerns, symptoms or challenges to your facilitator.  Failure to do so may result in the termination of Pancha Karma treatment. We reserve the right to refuse Pancha Karma treatment at our discretion. I also understand that I will be asked to rest during this time, which means that I will forgo participating in strenuous or stimulating activity of any kind including: late nights, boating, sexual activity, surfing, kayaking, helicopter flying, riding in a convertible, horse-back riding etc. I understand that the food used during Pancha Karma is a mono diet of kitchery, a simple ‘one pot meal’ of beans, rice, herbs, spices and simple vegetables.  The reason for this is to give substantial, nourishing, easy to digest food while giving the digestive system a rest during this cleansing time.
Women:   If your menstrual cycle begins during the course of Pancha Karma, treatments may need to be modified or discontinued.  Therefore, please schedule a session that will not coincide with your cycle. 
For all retreats: I hereby state that I have answered all these questions to the best of my knowledge.  I understand that this retreat 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 L.L.C., The Ayurveda Center of Hawaii, it’s staff, or any affiliated people or organization from any claims I may make.  

Optional Services:
During your Pancha Karma there are optional services that you may either want to receive or that may be suggested to you. In addition
you are expected to keep a similar diet for the week before as well as the week after your Pancha Karma retreat.  Many people find it both convenient and nourishing for us to make food for the arrival, departure and other non Pancha karma days, please give us as much notice as possible if you would like us to do so.  

Food options:
1. Basic Kitchery (or Dahl and rice) $45 per day
2. Add 2 additional side dishes an additional $45 per day
3. Deluxe meal pkg is $100 per day, 2-3 veggie side dishes, soup, dahl and rice or kitchery, customized tea blends, maybe chutneys. 
Other Options:
Shirodhara, one hour - $125, series of 5 - $600 or series of 7 - $825
Shirodhara, 45 minutes- $100 or series of 5 - $475, series of 7- $650
Ayurveda Herbal mineral mud wrap - $115 or series of 7 - $775
or rub and wrap (also called utvartana) - $115  or series of 7 - $775
Customized yoga/meditation lesson - $125 an hour an half
Ayurveda and Psychology counseling session - $75 per hour or increment thereof. 

Important Retreat Information:
* We will ask for your flexibility around scheduling.
* Please plan to have at least one day (if not two or three) on each side of your Pancha Karma days for rest and relaxation.
* This is not the time to plan any physically strenuous activities/exercise, such as: helicopter rides, boat or horseback riding, hiking, sight seeing. In fact this is an inward time, to be still, do less and simply be. Please plan to do sight seeing and strenuous activity for another trip so you can really focus on going within.
* Please make sure you have received an approval before scheduling your travel plans.
* Dates are confirmed by a 50% deposit of your total pancha karma cost,  (includes a 4.167% general excise tax for the State of Hawaii.) Deposits are non refundable but transferable. Some people like to offer gratuity to their technicians, this is not mandatory but appreciated.
* Since it makes for a seamless, deeply relaxing experience when you do not have to drive, do your best to stay on premises at the Hanalei Colony Resort www.HCR.com, or ask for a vacation rental in Haena.
* Plan to have an at home preparation consultation (by phone), and to shift your diet the week before as well as the week after your pancha karma cleansing and rejuvenation program.
* Please call Darci Frankel (or email) directly to set up your preparation consultation which should be at least 10 days before your first day of on site Pancha Karma.

By signing below, I agree to that I am completely responsible for my physical and psychological health and wellbeing and that I completely understand and agree with the contents here within.

Print your full name here_______________________________

Sign here_____________________________________________

Date_________________

The prices quoted on the website and brochures reflect the current cost of basic Pancha Karma. Additional ‘therapies’ such as Shirodhara and individual yoga instruction may be indicated for your body/mind type and are an additional charge.

Basic Pancha Karma includes daily traditional Ayurvedic warm oil massages from two experienced therapists, full body steam treatments, delicious healing foods, guidance through the appropriate cleansings when your body is ready, several hours of Ayurvedic consultations including periodic pulse analysis, yoga and more all in a beautiful, serene relaxing environment. Our prices are affordable. Enjoy your Purva and Pancha Karma!

Please do not hesitate to contact us should you have any questions, comments or concerns.
We look forward to having you on Kauai for a truly magnificent time of healing and discovery.
See you soon.  Aloha!!

Cut, paste and email registration above forms to darciayur@gmail.com

 

Relax, Recharge and Rejuvenate with us!
808.826.6621 email darciayur@gmail.com

www.PanchaKarma.net        www.HanaleiDaySpa.com

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