PORTUGAL PANCHAKARMA OCTOBER 2019 CUCUMBI | PANCHAKARMA | APPLICATION Full Name*Email* TelephoneAgeWhere do you live?How is your overall health? Under doctors supervision With some health issues Average Above average HEALTH ISSUES - Please list any illnesses or health issues. Make sure to list all present medications and or treatments. YOGA - What level is your yoga practice? Complete beginner Occasional yoga class As often as possible Dedicated practice I am a yoga teacher GOALS - What would you like to accomplish by attending this program?PLEASE READ AND CHECK BOX* I have read and agreed The Amaveda detox program is for educational purposes and is not intended to treat, cure, mitigate or prevent any disease. Any participant with a serious medical condition or taking prescription medication should check with their health care practitioner before following the detox program. The physician who has prescribed any medications you are taking must be aware of your intention to follow a detox program. I have read the above statement and agree to take full responsibility for any results this program may incur.