Online Application

Personal Information

Title

*First Name

*Last Name

*Name

Nickname

*Address

*City

*State

*Zip

*Telephone

*Phone

Fax

Business

Email

Occupation

Physical Stats

*Sex

*Height

*Weight

*Social Security #

Spouse's Name
(if applicable)

Children's Names
and Ages
(if applicable)

*Emergency Contact

*Name

Relationship

*Phone

Alternate Phone

Health and Treatment Profile

Current Diagnosis

Current Treatment Protocol

If receiving chemotherapy or radiation, date of last treatment.

*Are your blood counts low?

*Have you had to have blood transfusions?

*Have you taken Nupogen shots?

List any medications (prescription or over-the-counter) you are taking and any side-effects you are experiencing.

List any food supplements, herbs or other "natural" remedies you are taking.

*On a scale of 1-10, how would you rate your current health status ona day-to-day basis?  (10 being the best)

What are your most troublesome symptoms?

List any previous hospitalizations, surgeries, or diagnoses for which you have received treatment.

*Have you ever given yourself enemas for the purpose of colon cleansing and detoxification?

*Are you mobile enough to get up and down from the floor in order to administer enemas?

*Have you ever juice fasted?

How did you feel?

*Do you have difficulty climbing stairs or being at a high altitude?

Please check any of the following that apply to your situation:

Give details for the above selections as necessary?

Do you have any other health challanges that concern you?

What are your religious beliefs?

Thank you for completing this application.  Upon receipt and a $50.00 processing fee, it will be reviewed and a brief phone interview will be scheduled to address any concerns regarding your eligibility for the Lodge Program.  The HealthQuarters staff looks forward to being of help to you.  If someone is planning to attend with you, they must fill out an application, send a processing fee, and pay the deposit also.  There are no exceptions.

If my fee for the lodge program is being paid by scholarship, I acknowledge that I have informed the person(s) providing the scholarship tha tthe funds contributed on my behalf will be treated as a donation and is not refundable.  If I am unable to attend, the donation will be used as a scholarship for someone else, per IRS rules.  A tax deductible receipt will be provided.

Once a commitment is made and you are accepted into the program, a $1000 non-refundable/non-transferable room fee (per person) is required to hold the room.  The balance is due upon arrival.