1 – Participant Information

First Name *

Last Name *

Email *

Mobile Phone *

Date of birth *

Country

Retreat Dates *

How did you hear about us?

2 – Emergency & Primary Care

Emergency Contact Name *

Relationship *

Emergency Phone *

3 – Body Metrics

Height

Weight

6 – Medications & Supplements

Are you currently taking any prescription medications?

Yes

If yes, list medication name, dose, and reason.

Are you using diuretics or laxatives?

Yes

Supplements you are currently taking

7 – Lifestyle Snapshot

Caffeine intake (cups/day)

Alcohol (drinks/week)

Water intake (litres/day)

Exercise level

None

Light

Moderate

Intense

Have you done a juice cleanse before?

Yes

If yes, last cleanse length (Days)

Any adverse reactions to fasting or cleanses in the past?

9 – Allergies & Preferences

Plant allergies (e.g., celery, pineapple)

Ingredient dislikes (optional)

10 – Any other comments you would like to include:

Any other comments you would like to include 51fx

11 – Acknowledgments & Consent

I have read the retreat information and understand what a juice fast involves.

I acknowledge the potential risks (e.g., low blood sugar, electrolyte imbalance, headaches) and will seek medical advice if needed.

I agree to stop the cleanse and inform facilitators if I feel unwell, and to follow the provided break-the-cleanse guidance.

I confirm the information provided is accurate to the best of my knowledge.

Signature (full name) *

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