8 Day Program

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All deposits are non-refundable. By request, funds can be transferred to a future program dependent on availability.

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1 Welcome

2 Choose Dates

4 People in your group

Guest 1		First Name* Last Name* Email* Gender*
Guest 1		First Name* Last Name* Email* Gender*

After completing this form, emails will be sent to everyone in your group to complete their information.

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5 Book Shuttle

One way shuttle Kempsey to MM - arrival

One way shuttle from Kempsey to Misty Mountain Lifestyle Retreat.

AUD $80.00

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One way shuttle Port Macquarie to MM - arrival

One way shuttle from Port Macquarie to Misty Mountain Lifestyle Retreat.

AUD $100.00

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One way shuttle MM to Kempsey - departure

One way shuttle from Misty Mountain Lifestyle Retreat to Kempsey.

AUD $80.00

Select quantity

One way shuttle MM to Port Macquarie - departure

One way shuttle from Misty Mountain Lifestyle Retreat to Port Macquarie.

AUD $100.00

Select quantity

Return shuttle Kempsey to MM

Return shuttle From Kempsey to Misty Mountain Lifestyle Retreat.

AUD $110.00

Select quantity

Return shuttle Port Macquarie to MM

Return shuttle From Port Macquarie to Misty Mountain Lifestyle Retreat.

AUD $150.00

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6 Personal Information

Return Guest
Age *	Your age at time of program.
Preferred Name *	This will be the name used for your name badge and timetables etc.
Gender *
Phone *
Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Emergency Contact Info *	Please add name. contact number and relationship of emergency contact.
Occupation and length of employment *	eg. nurse - 20 years/office work - 5years/retired/SAHM, etc.
Marital Status *	eg. married/divorced/de-facto/single etc.
Children *
How did you hear about us? *
Arrival Time *	10:00am 10:30am 11:00am 11:30am Noon I require shuttle transfer Arrival times are for those driving themselves to the retreat - please note we use these arrival times to book in your individual consults. The first consult is 10:30am. The Shuttle service is strictly between 10am and 12pm the Sunday of arrival.
Shuttle Transfer (strictly 10am-12pm)	Hotel Bus Depot Train Station Airport Please note: Charges will apply for shuttle service.
Hotel Details	Please advise name and address of hotel
Bus Depot Details	Please advise bus depot address and arrival time.
Train Station Details	Please advise arrival time and train station.
Flight Number	Please advise flight number
Flight Arrival Time	Please advise arrival time at airport.
Departure Time *	I do not require shuttle transfer I require shuttle transfer
Shuttle Transfer *	Hotel Bus Depot Train Station Airport
Name & Address of Hotel *	Please advise name and address of hotel
Bus Depot Details *	Please advise bus depot address and departure time.
Train Station Details *	Please advise departure time and train station.
Flight Number *	Please advise flight number
Flight Departure Time *	Please advise departure time at airport.
Main Health Information *
All other health concerns
Cancer *
Details *	What type/stage/treatment/other info etc.
Current Stress Levels *	1 - lowest and 10 - highest
Current Energy Levels *	1 - lowest and 10 - highest
Height *	(Centimetres)
Weight *	(Kilograms)
Any metal fillings or root canals in your teeth? *	If none please write NA.
Any breathing or respiratory problems? *	If none please write NA.
How often do you exercise? *
Daily water intake *	(Litres)
Any digestive discomfort/disorders *	If none please write NA.
Regular bowel movements? How many per day? *
Any hormonal discomfort? (PMS, regularity, flow etc) *	If none please write NA.
Have you had any Covid-19 injections? *
Have you received any vaccinations other than for Covid in the past 5 years? *	If yes, please list all vaccines you have had.
Do you have any skin conditions? *	If none please write NA.
Do you have any aches/pains or headaches? *	If none please write NA.
Thrush/ Candida *	Thrush Candida NA Please tick relevant box
Have you had any significant exposure to known toxic chemicals, heavy metals, or mould? And if so, what and when? *	Please be as specific as possible to any exposure to the above
Do you have any issues with sleep? *	If none please write NA.
Have you had any surgical procedures? *	If none please write NA.
Do you have pets? If so, do they live in or outdoors? *	If none please write NA.
EMF Exposure *	I live or work near a 5G tower. I sleep near a smart meter. I leave my wi-fi on at night. Other I keep my phone on my person during the day I work on devices majority of my work day Please tick only those that are relevant to you.
Do you have any known genetic disorders? *	If none please write NA.
Please list any childhood illnesses *	If none please write NA.
Please list any current medication *
Please list any current supplements *
Do you consume any of the following substances? *	Coffee Tea Alcohol Cigrarettes Other None of the above
Other:	Please confirm 'other'
Mobility *	Overall Mobility Rating 1 - lowest and 10 highest. Please note we are not wheelchair or motorised-scooter friendly at this stage. Please also note we are quite hilly and guests participate in walking and exercise each day.
Health *	Overall Health Rating 1 - lowest and 10 - highest. Please note that we are not a medical facility and are an hour from the nearest hospital. If you are in serious need of medical attention, please consult your medical professional.
Do you have a belief system? *	If none please write NA.
Comments or Special Needs *
Typical breakfast *	List the foods you eat for breakfast.
Typical lunch *	List the foods you eat for lunch.
Typical dinner *	List the foods you eat for dinner.
Do you eat Cultured foods?	Examples are Sauerkraut, Miso, Natural Yogurt, Kefir, Kombucha, kimchi, Natto, Tempeh and Sourdough
Snacks *	List the snacks you have throughout the day.
Allergies	Please list all (and ONLY) foods you are allergic to. Any personal preferences are to be added to 'Dietary Requirements'.
Diabetic
Sugar Free	Please tick if you are on a sugar free diet. Please tick also if you have cancer, thrush or candida.
Lentils/legumes	Please advise if you eat lentils and/or legumes.
Dietary Requirements	Please add any personal preferences or anything else you think we should know.
1st Treatment *	Please choose 1st included treatment. See website for treatment explanations. For guests completing 15 day program you can include your 2 remaining treatments in 'additional treatments'.
2nd Treatment *	Please choose 1st included treatment. See website for treatment explanations. For guests completing 15 day program you can include your 2 remaining treatments in 'additional treatments'.
Additional Treatments	Alkaline Wrap $95 Alkaline Wrap x5 $425 Beautiful Eyes Package $70 Body Brush Treatment $95 (without the take home brush $65) Body Salt Glow $140 Coffee & Chocolate Detox Scrub & Body Wrap $135 Colonic Irrigation $130 Crystal Stone Facial $150 Deep Cleansing Facial $140 Deluxe Manicure $85 Deluxe Pedicure $110 Ear Candling $75 Express Feet & Face Treat $90 Gua Sua Facial $130 Head Massage $70 Hot Stone Massage $130 Hyperbaric Therapy $95 Hyperbaric Therapy x5 $425 Lymphatic Massage $130 Misty Signature Facial $120 Organic Age-Defying Firming Body Wrap $75 Organic Coconut & Honey Facial $120 Radiant Glow Hot Stone Facial $145 Sitz Bath $70 Sitz Bath x5 $250 Sitz Bath x10 $450 Swedish Massage $120 Waxing from $20+ Wood Therapy Massage $140 Wood Therapy Massage x3 $390 Remedial Massage $140 Please tick additional treatments desired. See website for detailed explanations of treatments.
Subject to availability, we offer a complimentary Live Blood Analysis to gain deeper insight into your health. Would you like this? *	Yes No
Body Composition Scan	If you would like a complimentary Body Composition Scan (subject to availability), you must register in advance via the link below: https://app.evoltactive.com/ Please use your email address and mobile number when registering.
Bathrobe *	XS S M L XL Please choose a size. Please note bathrobes are for use at the retreat only and not to be taken home. Sizes over XL for your comfort please bring your own robe.
Email newsletter	Please send me the email newsletter
Terms and Conditions *	I accept the terms and conditions.All deposits are non-refundable. By request, funds can be transferred to a future program dependent on availability.
If you are coming as a couple, would you like a separate consultation, or a consultation together?

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7 Security Check

Security check

8 Payment

Sub Total	$0

Donations	$0

Taxes	$0

Deposit	$0

Due Now	$0 $0

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	Bank Transfer - Payment instructions Your registration will be complete once we receive your payment.Please send your funds to: Misty Mountain Lifestyle Retreat BSB: 082 570 AC: 90019 6598 Reference: Please include your full name with your payment — otherwise we will not be able to match it to your registration SWIFT CODE (International Guests): NATAAU3303M Click on the button below and these instructions will be repeated on the next page.

	You will be asked for payment details in the next step. Click the button below to continue.

	By submitting payment, you authorise Misty Mountain Lifestyle Retreat to send instructions to the financial institution that issued your card to take payments from your card account in accordance with the terms of Misty Mountain Lifestyle Retreat's agreement with you.

1 Welcome

2 Choose Dates

3 Choose Room

Select an option*

Lodge Rooms - Standard

Lodge Rooms - Deluxe

Hilltop Room - Deluxe

Hilltop Room - Twin

Hilltop Rooms - Standard

Ensuite Room

Family Units

Mirriwinni Maths Room

Mirriwinni Home Economics Room

Mirriwinni Science Room

4 People in your group

5 Book Shuttle

6 Personal Information

7 Security Check

8 Payment