Agreement Philippines

Please be kind enough to fill the form below so we can serve you better.

Your Group Trip to the Philippines is Booked

Please note that all fields followed by an asterisk must be filled in.

First Name*

Last Name*

Gender*

Year of birth*

Your weight in kgs

Your height in cms

Email address*

City

Country*

Cell Phone Number including country code*

Next of kin name, phone number and email address to contact in case of emergency:*

Specify which to use to contact you + your id: Skype, FaceBook, WhatsApp, Viber or Messenger

If sharing a room, full name of your partner. He/she must fill another form if he/she wants a consultation

Day & Time of arrival in Manila*

Return Flight Date & Time*

If you intends to join my lectures (you must speak good English) please explain your health problems. This will be used by Patrick to help you.*

What medication(s) are you taking?*

What vitamins/ herbs are you taking?*

Do you exercise? Which and how often?*

Do you eat any organic foods? Which and how often?*

I eat at least 3 vegetables daly for lunch and dinner*

	True
	False

I eat chicken*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat pork or beef*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

Other meat I eat:*

I eat eggs*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat fish or other sea food*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat dairy products from cow, goat, sheep, (butter, yoghurt)etc..*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat gluten products such as bread or cakes or biscuits or floury products (i.e. pasta..) or wheat food *

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

How often do you eat seeds, nuts, avocados, hummus, coconut flesh or milk, or other oily products?*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I use oil for frying or in salad

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat tropical fruits (oranges, bananas, kiwi, mangoes, etc..)*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat tin food or pre-prepared meals*

	True
	False

I always check labels to make sure I don't eat any harmful chemicals (additives, coloring, sugar, etc..)*

	True
	False

If you have only recently changed your diet to the above. Please state when you changed it, and what your previous diet was

I drink alcohol*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I smoke*

	True
	False

Other comments

How did you hear about our trips?*

Confirm your acceptance of our Agreement at www.therapies.com/agreement.html on behalf of ALL travelers*

	I/we have read it and I/We agree to its terms
	I/we have not read it but agree to it anyway

Please enter the word that you see below.