予約フォーム  The Farm

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Peak Period

 

2020 PEAK PERIOD

イースター

48(水)~12日(日)

クリスマス / ニューイヤー2021

1220日(日)~11日(土)

 


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問診票

Guest Health Questionnaire

 

Date:

The information you provide by completing this questionnaire will allow our medical doctors to define your personal program here at The Farm.

Last Name:

First Name:

Title:

Ethnic Origin:

Blood type:              Civil Status:

Gender:

Date of Birth:

Age:

Height:

Weight:

Contact Number/s:

 Email:

Nationality: 

Country of Domicile:

         

 

Please, indicate your main health concern, if any.

 

 

Please state the diseases, symptoms, or disorders that you are experiencing for the last 6 months:

 

Please list medications utilized during the course of the past six (6) months. Please, include vitamins and dietary supplement

 

 

Have you undergone surgery in the last 2 years?

    If yes, please indicate the reason for the surgery and the date the surgery was performed.

 

Have you had colon hydrotherapy or other colon cleansing treatment before?

    If yes, please indicate the date, the name of the institution and the country

 

Please, indicate the MAXIMUM duration you are able to stay: 

    The Medical Doctors will prescribe the duration of the program on the basis of your state of health

    and the health goals you have defined, as well as allowable time away from work and family.

 

Please, provide information regarding any known ALLERGIES (drugs, vitamins, minerals, herbs, food) and FOOD INTOLERANCE that you may have:

For spa considerations, are you skin allergic to coconut oil?

 

Do you smoke cigarettes, cigars? How often?

 

Do you drink alcoholic beverages? How often?

 

Are you a CIGNA member/cardholder?

 

                            YES                                            NO

 

Are there any other concerns or information that you wish to add that may assist us in maximizing your stay at the Farm?

 

 

     

* For your best health interest and with your permission, your program inclusion can still change AFTER consultation and physical check-up with our medical doctor based on health concerns not previously mentioned. 

* Charges will apply for additional services outside your pre-booked program

* Email filled out Guest Health Questionnaire to thefarm@zaz.att.ne.jp

 

Agreement of Program Terms and Conditions

This document delineates the terms and conditions by which the guest agrees to abide for the duration of stay at The Farm, located at 119 Barangay Tipakan, Lipa City, Batangas, and Republic of the Philippines (hereafter referred to as “The Farm”. The scope of The Farm is to provide guests with progressive therapies designed to cleanse and strengthen physical, mental, and emotional health. The services and products offered include educational classes, raw and living (high-enzyme) meals, general fitness exercises sessions, massage, life and lifestyle coaching. The services and products defined and delineated by medical personnel of THE FARM individually for the guest signing hereunder shall hereafter be referred to as “the Program”. The person signing hereunder and either intending to purchase a service or a product of THE FARM or having purchased a service or product of THE FARM shall hereafter be referred to as “the Guest”. 

 

A. CLEANSING AND NUTRITIONAL PROGRAMS  1. I understand that THE FARM practices holistic, alternative, natural medicine. The education provided by THE FARM is for improving health through body cleansing and maintaining optimal health through quality nutritional and lifestyle practices of the Guest. 

 

2. I understand that the disciplines and modalities offered as services by THE FARM are not exact clinical sciences (conventionally defined as double-blind control trials in multi-centers). I acknowledge that no claims or guarantees have been made to me regarding my health as a result of my using the disciplines taught by THE FARM. 

 

 3. By voluntarily enrolling in the Program on my own free will, I fully understand and take full responsibility for my decision to learn progressive health disciplines and for any and all risk that may be involved in my participation in the Program. THE FARM shall not be held liable for any consequences that may occur whether directly or indirectly linked to the Program, either during or after my completion of the Program. 

  

4. I understand that the decision to enroll in the Program may involve discomfort resulting from the process of detoxification (internal cleansing), dietary and lifestyle changes. I understand and agree to notify medical personnel of THE FARM of any unease or discomfort I may experience during the Program, and of any sign or indication.

 

5. I understand that I am to receive guidance regarding therapeutic treatments and modalities for the Program only from medical personnel of THE FARM 6. I understand that for optimal efficacy of the Program, I am required to comply with the Program, adapt a healthy and positive openness, and that without openness the results of the Program may not be optimum. 

   

7. THE FARM does not accommodate persons in need of nursing care. I do not require such care at this time. 

 

 8. I agree that, should I need emergency medical care during my stay at THE FARM, I will so notify medical personnel of THE FARM, and agree to leave the premises of THE FARM if instructed by medical personnel of THE FARM to do so in the best interest for my health. I agree that THE FARM shall not be responsible for transportation or medical expenses incurred in conjunction with emergency evacuation and emergency medical care I may require. 

 

 B. GENERAL  1. I understand and agree that THE FARM is not liable for the loss or damage of money, jewelry or other valuables and personal possessions. 

  

2. I understand and agree that THE FARM reserves the right to terminate the Program if I neglect to observe and abide by the guidelines pertaining to the Program or any instruction by medical personnel of THE FARM. 

 

 3. I understand and agree that in the event that medical personnel of THE FARM terminate the Program on the basis of my neglect to observe and abide by the guidelines pertaining to the Program

 

 THE FARM AT SAN BENITO Resort Address: 119 Barangay Tipakan, Lipa City, Batangas, Philippines Mobile No. (+63)9188848078 Sales and Reservations Office: Shop 12, G/ F, The Peninsula Manila, Corner of Ayala and Makati Avenues, Makati City, Philippines Tel. Nos. (63 2) 884 8074 Mobile No. (+63) 9188848080 Email: reservations@thefarm.com.ph Website: www.thefarmatsanbenito.com

 

or any instruction by medical personnel of THE FARM, I shall be responsible for remitting the full amount of the payment of the Program, as stated by the Statement of Account document issued by THE FARM, whether I may have completed the Program or not. 

 

 I confirm to have read, understood and to agree to the terms and conditions delineated above. I hereby willfully agree to waive all my rights for filing any legal case against THE FARM, the services, products and the Program offered by THE FARM, and any and all services products and the Program I may have received, purchased or received from THE FARM.

 

 

 _______________________ Signature over Printed Name               Date:             

  

 Thank you for taking the time to complete the form. We will contact you by telephone or email as soon as your program has been defined. 

  We look forward to welcoming you to The Farm. 



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