Ceylon Breathe Ayurveda
CEYLON BREATHE AYURVEDA · SRI LANKA
BOOK CONSULTATION
Guest Reservation
RESERVE YOUR STAY

Guest Reservation &
Wellness Registration

⊙

Complete the form below to reserve your stay and register for a personalised Ayurveda wellness programme. Every detail you share helps our physicians design a safe, effective treatment plan exclusively for you.

Reservation Reference Assigned on submission
Date of Reservation —
CEYLON BREATHE AYURVEDA (PVT) LTD

Ayurveda Wellness Resort
Reservation Form

Please complete every section as accurately as possible. Fields marked * are required. All information is transmitted securely and used solely for reservation, medical consultation and wellness programme purposes.

🔒 Your personal and medical information is kept strictly confidential.
This form auto-saves as you type, in this browser only.
1 Guest Personal Information
Title *
Please select a title.
Please enter your full name as it appears on your passport (letters only).
Please enter a valid date of birth.
Gender *
Please select a gender.
Please enter a valid nationality.
Please enter a valid country.
Please enter a valid passport / ID number (5–20 letters/numbers).
Passport expiry date must be a future date.
Please enter a valid email address.
Please include the country code, e.g. +94 767003738.
Please enter your residential address.
Emergency Contact Person *
Required.
Required.
Please enter a valid telephone number.
Please enter a valid email address.
2 Travel & Accommodation Details
Please choose an arrival date (today or later).
Departure date must be after the arrival date.
Please enter at least 1 adult.
Preferred Accommodation *
Please select a room type.
Bed Preference *
Please select a bed preference.
Extra Bed
3 Flight & Airport Transfer
Airport Pickup Required? *
Please select Yes or No.
Airport Drop Required? *
Please select Yes or No.
Please enter a valid flight number.
Please enter a valid flight number.
4 Ayurveda Wellness Programme
Preferred Programme *
Please select a programme.
Your Objectives * (select at least one)
Please select at least one objective.
Programme Duration *
Please select a duration.
5 Health Assessment Questionnaire 🔒 Shared only with your treating physician — kept strictly confidential.
Please describe your primary health goal.
Blood Pressure *
Please select an option.
Diabetes *
Please select Yes or No.
Heart Disease *
Please select Yes or No.
Asthma *
Please select Yes or No.
Pregnant * (if applicable)
Please select an option.
Please enter a valid height (50–250 cm).
Please enter a valid weight (20–300 kg).
Smoking *
Please select Yes or No.
Alcohol Consumption *
Please select Yes or No.
Known Ayurvedic Dosha
Dietary Preference *
Please select a dietary preference.
6 Food & Lifestyle Preferences
Preferred Meal Plan * (select at least one)
Please select at least one meal plan.
7 Payment Information
Preferred Payment Method *
Please select a payment method.
Promo codes may only contain letters, numbers and hyphens.

Please note: a 50% deposit is required to confirm your reservation. Our team will send secure payment instructions after review — we will never ask for full card details by email.

8 Special Requests
9 Terms & Conditions
  • Check-in Time: 2.00 PM  |  Check-out Time: 12.00 Noon
  • 50% of the total amount is required as a deposit to confirm reservations.
  • Cancellations within seven (7) days of arrival are subject to a 50% cancellation fee.
  • No-show reservations will be charged 100% of the booked amount.
  • Ayurvedic treatments are wellness therapies and are not intended to replace emergency medical care.
  • Guest medical information will remain strictly confidential.
  • Management reserves the right to modify treatment schedules based on medical assessment.
You must agree to the Terms & Conditions to proceed.
Please type your full name as your electronic signature — it should match your full name above.
* Security check: 4 + 7 =
That answer isn't quite right — please try again.

🔒 Submitted securely. Our reservations team will confirm availability and payment details within 24 hours.

✓

Āyubowan! Your Reservation Has Been Received

Thank you for choosing Ceylon Breathe Ayurveda. Our reservations team will review your details and reach out within 24 hours to confirm your stay and wellness programme. A confirmation has also been emailed to you.

Reference: CBA-000000

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