Book a Restore and Revitalise retreat

Please fill in all the sections as fully as possible. We use the information to assess that you’re well enough to attend and to make sure that we take into consideration your needs once you are here. Once we’ve received your form we’ll contact you by email to let you know that your booking is confirmed and to provide further information.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Please include your country code

What you would like to book

Which retreat would you like to book?

Are you coming on your own or would you like to bring someone with you?

If you are coming with someone what is their relationship to you?

If you are coming with someone what sort of bedroom do you require?

Please note that we give priority to people with cancer so it may be that your guest will have to share with you.

Does the person accompanying you want to participate in the full programme?

Please tell us briefly why you would like to come for a Restore and Revitalise retreat

How did you hear about Puissentut?

How do you identify yourself?

How old are you?

Cancer and medical history

When were you first diagnosed with cancer?

What type of cancer were you diagnosed with?

Do you have secondary cancer?

Where do you have secondary cancer?

What stage cancer do you have?

Please tell us about the medical treatment you are having or have had.

Please tell us which complementary or alternative treatments you are having of have had.

Please tell us about any side effects, complications or symptoms you are currently experiencing as a result of your treatment.

Please tell us about any other prescribed or non-prescribed medicine you are taking?

Please tell us about any other medical or physical difficulties you may have?

Do you have any mental health issues we should be aware of?

Do you have any allergies we should be aware of?

Please tell us about any specific dietary requirements you have?

Insurance

Do you have medical insurance, or a Global Health Insurance Card (GHIC), that will cover you for medical treatment in France during your entire stay at Puissentut and in France?

Do you have travel insurance valid for the entire time you want to visit Puissentut?

Your medical team

In case of medical difficulties or an emergency during your stay at Puyssentut, we would be grateful if you would supply us with contact details for your doctor and oncologist.

Your doctor

First Name

Last Name

Practice address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

May we contact them?

Your oncologist

First Name

Last Name

Department and Hospital

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

May we contact them?

Are you well enough to visit Puissentut?

Are you in a lot of pain?

Do you have a low blood count that may put you at risk of infection?

Do you have an infection or infectious illness that may put others at risk?

Do you have a stoma or a catheter?

Do you need nursing or medical care, for example, injections, dressings etc?

Nursing or medical care is not included in the cost of your stay? Are you able to pay for any extra costs that you incur?

Please tell us about any specialist care you need:

Do you need help walking or do you use a wheelchair?

Please give details:

Please tell us here anything else we should know about your health:

Have you consulted your doctor or oncologist about your intended visit to Puissentut? Do they support your plans to stay at Puissentut?

Emergency contact details

Please tell us who we should contact in your family or amongst your friends in the case of emergency or if there is a medical or non-medical need during your visit.

Name

First Name

Last Name

Phone

Email 1

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Relationship to you

Use of information

All information is kept confidential and is used only to help us provide you with a safe and comfortable stay at Puyssentut. To help the therapists and teachers working with us fit their workshops and classes to your needs and abilities, we may want to share some of your information with them, are you happy for us to do this?