Infinite Life Wellness LLC Retreat Submission Form

Please fill out this form so we can prepare everything needed to create a personalized plan just for you. Your answers help us tailor your experience to fit your body, goals, and needs.

Basic Information

Full Name *

Preferred Name

Date Of Birth *

Email *

Phone *

Current Symptoms

Perimenopause Symptoms *

Hot flashes

Night sweats

Sleep disturbances

Brain fog

Anxiety

Mood swings

Low mood

Fatigue

Weight changes

Low libido

Joint pain

Headaches

Medications & Supplements

List all prescription medications *

Supplements & Herbs *

Sleep & Lifestyle Notes

Intentions for the Retreat

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, and new product updates. Message frequency may vary. Message & data rates may apply. Reply HELP for help or STOP to opt out. Your information will never be shared or sold.

Retreat Guidelines Agreement *

I agree to the retreat guidelines: limited parking (carpool when possible), guests not staying onsite must leave by 10pm, quiet hours after 10pm, no smoking, no unticketed guests.

Thank you

your responses help us support you safely and thoughtfully during the retreat.