Either fill out the form below or go to the Printable Fasting Registration Form.

Note: Fields marked with a * are required.
General Information
  I am interested in: A Consultation A Supervised Fast
  Preferred Dates & Times:
  Total Days: (if fasting)

Contact Information
  First Name* Last Name*
  Company Name: Email*:
  How you heard: Phone (h)*:
  Details about how you heard
  (friend's name, website address, etc.):
  
Phone (w):
Phone (cell):
Fax:
  Address 1*: Address 2:
  City*: State/Prov.*:
  Zip*: *

Emergency Notification (required for Supervised Fast participants)
  In Case of an Emergency Contact*: Relationship:
  Phone*: E-mail:

Additional Information
  Date of Birth Year: (e.g. 1976)
  Gender: Male Female
  Occupation: Height:
  Weight: Age:
  Marital Status:
  (Single/Mar/Div/Sep)
No. of Children:


Health and Medical History
If you don't have an answer, or if the question doesn't apply to you, please leave it blank.
What is your current diet?
Present Health Problem:
How long has this been a problem?
Surgeries Type(s):
Surgeries Date(s):
List Complications:
Recent hospitalizations:
Present Medications/Hormone Treatments/Supplements:
Allergies:
Are you pregnant, or think you might be? Yes No

Check any Present Issues and any Important Previous Illnesses:
Anemia/blood disease
Arthritis
Asthma
Back or neck problem
Blood in stool
Bruise easily
Cancer
Chicken pox
Chronic cough
Clot in veins
Colitis
Constipation
Depression
Diabetes
Diarrhea
Dizziness, fainting
Epilepsy
Excessive worry
Eye trouble
Fatigue
Frequent anxiety
Gain/loss of weight
Gall stones
Gall bladder problems
Gas or bloating
Gum or tooth problem
Headache
Heart problem
Hemorrhoids
Hepatitis
Hernia
High blood pressure
High cholesterol
HIV/Aids
Hypoglycemia
Intestinal problem
Jaundice
Kidney problem
Lipo-suction
Measles
Migraine headaches
Mononucleosis
Mumps
Muscle cramps
Nervousness
Obesity
Pain in chest
Palpitations
Phlebitis
Pneumonia
Pregnant (currently)
Psychiatric problem
Pseudoatrophy
Rheumatic fever
Scar problems
Sensitive skin
Sinus/nose problem
Shortness of breath
Skin problem
Sleep problem
Stomach problem
Swollen glands/lumps
Swollen joints
Throat problem
Thyroid disease
Tuberculosis
Tumor, Cyst
Ulcer
Varicose veins
Veneral disease
Vision problem

Men
Prostate problem
Testicle problem

Women
Birth control pills
Breast problem
Excessive flow
Irregular periods
Pregnancy problems
Vagina/uterus problem
Please explain any that you checked above:
Do you use tobacco? If so, how often?:
Do you drink alcohol? If so, how much?:
Do you drink coffee? If so, how much?:
How much water do you drink a day?
Do you exercise? Yes No
If so, how often?:
Have you ever fasted before? Yes No
If yes, was it with water or juice?
Have you ever visited TWC before?
List other detox program(s):
Have you been on a weight loss program(s)?
Please use this area to explain in detail the health concerns you have and what you have done for them:

Agreement between the Tanglewood Wellness Center, S.A. and Guest

I, , hereby affirm that:

  1. I have come to the Tanglewood Wellness Center to enjoy the climate and ambiance here and to learn more about Loren Lockman's ideas and philosophy about health, vitality, fasting, and fitness.
  2. I am fully aware that Loren Lockman is not a licensed medical doctor or nutritionist and holds no licenses to practice medicine or alternative medicine. No claims or guarantees have been made to me about the outcome of the choices I may make.
  3. I am here of my own free will and take full responsibility for the choices I make. I have not been coerced, forced, or pressured into doing anything. Whether I choose to follow Loren's ideas or not is completely up to me and I acknowledge that should I choose to fast, going without food for any length of time is a serious process which can be challenging and may create difficult and uncomfortable symptoms.
  4. I understand that the only food available at the Tanglewood Wellness Center is fruit and simple green salads. It is my choice to eat only these things while here and I take full responsibility for any effects of doing so.
  5. I agree to hold harmless and to absolve all others from any responsibility for my health and well-being, including Loren Lockman, the Tanglewood Wellness Center, the village of La Mercedes, District of Hojancha and its health service, the Province of Guanacaste, and the State of Costa Rica. I alone take 100% responsibility for what I do and the outcome of it.
  6. I understand that the funds I've paid to be at Tanglewood are for my room and the use of the retreat facilities and once paid, are completely non-refundable. Should I choose to not come or leave early, no refunds will be made.

I acknowledge that I am undertaking a potentially transformative process here at Tanglewood and understand that this can be difficult in many ways.

You can download this agreement here.

By checking this box and submitting this form, I acknowledge that I have read and understand the above terms, and hereby agree to them.


Deposit or payment amount (if determined at this time)*.
Your Subtotal $
Deductions, such as gift certificates. $
Gift certificate number ID:   
Your Total $
Please enter the imaged text in the box provided.*