Enquiry form

Phone

First Name

Last Name

Date of Birth

Sex

Nationality

Place of Residence

Hereby I give my consent that Amrtasiddhi may use the information provided in this form to contact me regarding my enquiry and prepare a non-binding reservation offer.

Your Ayurvedic Program

I know which Program I want to participate in

I'm not sure which Program to choose and need further assistance

Please select your Program

Please choose

Please give me a call

I will specify my request in the message field below

To prepare for your phone conversation with us, think about how you would answer the following questions:

What are your main reasons for wanting to participate in a Program at AmrtaSiddhi?
What are currently your major Health challenges?
What is the maximum length of time you can dedicate to a Program?

Skype Name or Phone Number

I am in Time Zone

Preferred Time Option 1

Preferred Time Option 2

Preferred Time Option 3

Please consider answering the following questions:

What are your main reasons for wanting to participate in a Program at AmrtaSiddhi?
What are currently your major Health challenges?
What is the maximum length of time you can dedicate to a Program?

Upon receiving your answers, our Physicians can recommend the optimum program for you.

Subject

Message

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Select your Accommodation

Single occupancy

Double occupancy

No accommodation

Choose "Double Occupancy" if you want to share a room with your Partner/Friend. Choosing "Double Occupancy" does not mean that AmrtaSiddhi will allocate someone to share a room with you.

Preferred Room Type (Single Occupancy) Preferred Room Type (Double Occupancy)

Sharing Room with (Name)

Sharing with person

The Person I’m sharing room with wants to enroll in the same program with the same Check-in/Check-out dates and same Program Start/Program End dates.

The Person I’m sharing room with wants to enroll in a different program or has different Check-in/Check-out dates or different Program Start/Program End dates. Please ask your Partner/Friend to fill in a separate Enquiry Form.

The person I’m sharing room with is not planning to enroll in a program with AmrtaSiddhi.

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Your selection: 14-Day Weight Loss Program

Please select your Check-in Date

Programs generally commence 1 day after check-in and the check-out date is set to coincide with the Program end date. You may add extra treatment days to your chosen Program and additional nights accommodation before and/or after your Program end.

Nights Before Treatment

Treatment days

Nights After Treatment

Your Itinerary

Selected Program:-
Check-in Date:-
Program Start:-
Program End:-
Check-out Date:-

Choose your pick-up location

Airport

Hotel/Villa

Not necessary

I don't know yet

Flight Itinerary

I already have my flight information

I don’t have my flight information yet

Resort/Villa Address

Resort/Villa Phone Number

Pick-up Date

Pick-up Time

Arrival Date

Arrival Time

Arrival Flight No

Your Itinerary

Selected Program:-
Program Start:-
Program End:-

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Personal Information

E-Mail:-
Phone:-
First Name:-
Last Name:-
Date of Birth:-
Sex:-
Nationality:-
Place of Residence:-

Program

Selected Program:-

Accommodation

Room Type:-
Occupancy:-

Itinerary

Selected Program:-
Check-in Date:-
Program Start:-
Program End:-
Check-out Date:-

Additional Comments

Please note that this form is not a binding reservation.

I have read and agree to AmrtaSiddhi’s Terms & Conditions.

I have read and agree to AmrtaSiddhi’s Rules of Engagement.

Itinerary

Selected Program:-
Program Start:-
Program End:-

Additional Comments

Please note that this form is not a binding reservation.

I have read and agree to AmrtaSiddhi’s Terms & Conditions.

I have read and agree to AmrtaSiddhi’s Rules of Engagement.

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Enquiry form

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