Hanalei Day Spa & The Ayurveda Center of Hawaii
Important Information about the Registration Application:
Cut and paste the application below
directly to your email.
Registration application needs to be accepted before you make
your travel arrangements
dates are not secure until deposit is received.
Deposit WILL BE REFUNDED to you if your application is not
accepted at this time.
Please complete this form
and send it in with two current photos; close up of face and
clothed full body.
Take as much space as you
This information is
Birth data: / / time : (Accuracy is important here, for
Location: (city/state) where you were born
Home Phone: Cell Phone:
E Mail: Work:
Yes, I want to attend _______________________ retreat, a 50% deposit
is required to register.
Proposed Dates for _______________________ retreat or Pancha Karma:
From / /___ to / /___
Please charge my (Master or Visa) (card number) ___________________
CVV2 code (last 3 digits on the he back of card) ________ Billing
My intentions for receiving Pancha Karma are:
any of the following conditions that you have now or have had and
athletes foot (needs to be cleared up before treatment, ask for
remedy if you do not already have one), pregnancy, lactation,
hypertension, lympho-sarcoma, cancer of the lungs or testicles,
melanoma, congestive heart failure, HIV or AIDS, dehydration, or any
active infectious disease please explain.
Asthma, allergies, emphysema,
chronic fatigue syndrome, carpal tunnel syndrome, fibromialgia,
obesity, cigarette smoking current/past, Chron's syndrome, irritable
bowel syndrome, stomach ulcer, shingles, herpes simples/genitalis/zoster
(shingles), food addictions, substance abuse.
(This information is confidential.) Please document your
recreational drug/substance use of past, present and future.
Below, please describe your state of
health, current medical treatments,
illnesses, healing crises prescription
vitamins/herbs, and history of any
Please document any
allergies and/or food allergies, also, are you allergic to oils? If
so which one(s)?:
Please make sure that we receive your deposit before making airline
reservations. Rates are subject to change.
A 50% deposit is required to reserve your time and space. The
balance is due on day one of your retreat or Pancha Karma program.
We accept master, visa, discover and cash. If you would like a
receipt, please ask. The deposit is non-refundable yet may be
transferable under certain conditions.
Client Responsibility (For Pancha
This is a time to be inward, a time to
rest, recharge and become aware of your inner world. It should be
introspective and enjoy your Pancha Karma. If you are late or don’t
show for your scheduled treatments then you miss out on that day of
treatments. If you do not follow instructions, or use recreational
drugs during your Pancha Karma program this may result in the
termination of your Pancha Karma treatment and you may not receive a
refund. It is the
responsibility of the client to follow these guidelines and also
report any concerns, symptoms or challenges to your facilitator.
Failure to do so may result in the termination of Pancha Karma
treatment. We reserve the right to refuse Pancha Karma treatment at
our discretion. I also understand that
I will be asked to rest during this time, which means that I will
forgo participating in strenuous or stimulating activity of any kind
including: late nights, boating, sexual activity, surfing, kayaking,
helicopter flying, riding in a convertible, horse-back riding etc. I
understand that the food used during Pancha Karma is a mono diet of
kitchery, a simple ‘one pot meal’ of beans, rice, herbs, spices and
simple vegetables. The reason for this is to give substantial,
nourishing, easy to digest food while giving the digestive system a
rest during this cleansing time.
If your menstrual cycle begins during the course of Pancha Karma,
treatments may need to be modified or discontinued. Therefore,
please schedule a session that will not coincide with your cycle.
For all retreats:
I hereby state that I have answered all these questions to the best
of my knowledge. I understand that this retreat is not to be used
in place of medical treatment, and that I should check with my
doctor before making any changes to my diet or lifestyle.
Pancha Karma is a program
consisting of massages, and steam treatments and not a medical
treatment for any medical condition. I
agree to hold harmless Darci Frankel, Hanalei Day Spa L.L.C., Shanti
Enterprises Inc., The Ayurveda Center of Hawaii, it’s staff, or any affiliated people or
organization from any claims I may make.
During your Pancha Karma there are optional services that you may
either want to receive or that may be suggested to you. In
you are expected to keep a similar diet for the week before as
well as the week after your Pancha Karma retreat. Many people
find it both convenient and nourishing for us to make food for the
arrival, departure and other non Pancha karma days, please give us
as much notice as possible if you would like us to do so.
1. Basic Kitchery (or Dahl and rice) $45 per day
2. Add 2 additional side dishes an additional $45 per day
3. Deluxe meal pkg is $100 per day, 2-3 veggie side dishes, soup,
dahl and rice or kitchery, customized tea blends, maybe chutneys.
Customized yoga/meditation lesson - $100 per hour
Ayurveda and Psychology counseling session - $100 per hour or
* We will ask for your flexibility around scheduling.
* Please plan to have at least one day (if not two or three) on each
side of your Pancha Karma days for rest and relaxation.
* This is not the time to plan any physically strenuous
activities/exercise, such as: helicopter rides, boat or horseback
riding, hiking, sight seeing. In fact this is an inward time, to be
still, do less and simply be. Please plan to do sight seeing and
strenuous activity for another trip so you can really focus on going
* Please make sure you have received an approval before scheduling
your travel plans.
* Dates are confirmed by a 50% deposit of your total pancha karma
cost, (includes a 4.167% general excise tax for the State of
Hawaii.) Deposits are non refundable but transferable. Some people
like to offer gratuity to their technicians, this is not mandatory
* Since it makes for a seamless, deeply relaxing experience when you
do not have to drive, do your best to stay on premises at the
Hanalei Colony Resort www.HCR.com,
or ask for a vacation rental in Haena.
* Plan to have an at home preparation consultation (by phone), and
to shift your diet the week before as well as the week after your
pancha karma cleansing and rejuvenation program.
* Please call Darci Frankel (or
email) directly to set up your preparation consultation which
should be at least 10 days before your first day of on site Pancha
By signing below, I agree to
that I am completely responsible for my physical and psychological
health and wellbeing and that I completely understand and agree with
the contents here within.
Print your full name
The prices quoted on the
website and brochures reflect the current cost of basic Pancha
Karma. Additional ‘therapies’ such as Shirodhara and individual yoga
instruction may be indicated for your body/mind type and are an
Basic Pancha Karma includes
daily traditional Ayurvedic warm oil massages from two experienced
therapists, full body steam treatments, delicious healing foods,
guidance through the appropriate cleansings when your body is ready,
several hours of Ayurvedic consultations including periodic pulse
analysis, yoga and more all in a beautiful, serene relaxing
environment. Our prices are affordable. Enjoy your Purva and Pancha
Please do not hesitate to
contact us should you have any questions, comments or concerns.
We look forward to having you on Kauai for a truly magnificent time
of healing and discovery.
See you soon. Aloha!!
Cut, paste and email registration above forms to
Relax, Recharge and Rejuvenate with us!
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