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RASA AYURVEDA
US Phone 908-638-8843
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Info@RasaAyurveda.com
 
 
 

Registration for Residential Treatment

Name on Passport*
Name You Prefer to be Called*
Gender*
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Arrival Date*
Departure Date*
   
Coming for*: (check all that apply)
Addressing health issues  
Detoxing and rejuvenating thru Pancha Karma
Experiencing Ayurveda/Siddha Vaidya and taking personal retreat
Learning about traditional Ayurveda/Siddha Vaidya, herbal medicines, cuisine and culture
Not sure yet  
   
Please give us a few words describing what you hope to gain from your Ayurvedic diagnosis and therapies at Rasa Ayurveda
Traditional Healing Centre for Women*:
   
Email Address*
   
Address*
City*
State/Province* Zip/Postal Code*
Country*
   
Home Phone*
Mobile Phone
Work Phone
   
Emergency Contact Person*
Emergency Contact Telephone*
   
How did you hear about us?
   
My 50% deposit will be paid by:
   
I have read, understand and agree to the Rasa Ayurveda Traditional Healing Centre Terms and Conditions*
   
   

*Required

 

A date availability confirmation email from Rasa Ayurveda and your non-refundable deposit of 50% of the cost of your treatment will guarantee your reservations.

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Rasa Ayurveda is operated by
     MayaShakti Ayurveda Pvt. Ltd., India.
MayaShakti Ayurveda is dedicated to socially-conscious
     and ecological business principles.

 

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