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Registration/Payment - Register and Pay for your stay at Detox Oasis.
 
Name:
Email:
Phone:
Note:
 
 

Please fill out the following form to register for your stay with us at Detox Oasis.

 
Registration Form (step 1 of 4)
Detox Oasis/Fit Body Retreat Guest Personal History
   
Date Pick a date
Deposit Payment of by
Session Date Pick a date
Date Pick a date
Deposit Payment of by
   
*Name
*Address
*City
*State
*ZIP
*Country
*Phone
Alternate Work or Cell Phone
*Email Address
* Date of Birth Pick a date
 Age
 Sex
   
In Case of Emergency
* Contact Person
* Phone
   
* Length of Stay days
From Pick a date To Pick a date
* What type of previous programs have you tried?
* What type of diet have you been eating during the last month?
Diet Description
* Past Health Problems (please be explicit)
* How did you learn about Detox Oasis or Fit Body Retreat?
* In the last month, have you been on any oral medication? Yes No
Description of Medication
   

* Disclaimer Acknowledgement - I have read and agree to the following:

Fit Body Retreat; Detox Oasis; Elk Ridge, LLC; Rusk Elk Ranch, LLC and its owners, staff members and associates MAY NOT be held RESPONSIBLE WHATSOEVER FOR LIABILITY RESULTING FROM: ACCIDENT, INJURY, PARTICIPATION at Detox Oasis, or other mishap not herein described, which might occur on these/their premises.

I understand that: Detox Oasis - Fit Body Retreat does not offer/provide medical or health care of any kind for anyone. It is a natural nutritional health learning center dedicated to the living foods lifestyle or body building nutritional lifestyle. Arrangements for medical services are with a local physician with a private medical practice.

I am aware that: Detox Oasis - Fit Body Retreat is unable to accommodate anyone unwilling/unable to care for themselves and/or their needs.

 I also realize that: If I am now or become in the future unable to attend to my personal needs I will leave Detox Oasis or Fit Body Retreat, subject to the recommendations of its owner, staff members, or associates. I have read the above and hereby agree to participate in accordance with the program directives to cooperate with staff and associates in an effort to achieve its intended purpose and to pay in full on the first day of the program ALL charges commensurate with my particular program and personal accommodation.

   
* Signature
* Date Pick a date
   
Payment Details
   
* Date Pick a date
* Amount Purchased
Cleaning Fee
* Total
   
 Driver's License Number
   
Billing Address (No PO Box #'s)
*First Name
*Last Name
Company
*Address
Address 2
*City
*State
*ZIP
*Telehone Home
Telephone Work/Cell
   
Shipping Address (No PO Box #'s)
First Name
Last Name
Company
Address
Address 2
City
State
ZIP
Telehone Home
Telephone Work/Cell
   
* Payment Authorization
I hereby authorize Elk Ridge Resort, LLC, Detox Oasis, Fit Body Retreat, Ageless Medicine, LLC - its officers, agents, managers, unit holders, affiliates, employees, contractors, and representatives to charge me for the stated U.S. dollar amount effective this date. Purchaser agrees that no payment transaction shall be disputed by purchaser for any reason after the patient's name has been provided and/or received products and services and payment transaction has occurred. Elk Ridge, LLC and/or any of the above named affiliates reserves the right to refund or deny any payment at the company's sole discretion.
   
*Required
 
 


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