Personal Information : Email Address: (required) Retype Email Address: (required) Salutation: Mr. Mrs. Ms. First Name: (required) Last Name: (required) Address/Hotel (room number if available): (required) Phone: (required) Spa Activity Information: Date of Spa Activity : January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ,2021 2022 2023 2024 2025 2026 (required) Time : 09.00 09.30 10.00 10.30 11.00 11.30 12.00 12.30 13.00 13.30 14.00 14.30 15.00 15.30 16.00 16.30 17.00 Spa Operator : Type of Packages : Half day Spa Spa Beauty Package Tjampuhan Dewi Package Tjampuhan Bidadari Package Tjampuhan Ratu Package Tjampuhan Adventure Spa Aromatic Package Spa Harmony Package Traditional Mandi Lulur Traditional Balinese Boreh Tjampuhan Healing Massage Tjampuhan Body Scrub Beauty Facial Traditional Balinese Massage Acupressure Massage Swedish Massage Shoulder Massage Tjampuhan Face Massage Traditional Foot Massage Reflexology Massage # of Adults: 1 2 3 4 5 6 7 8 9 10 Credit Card Information: Card Holder's Name : Credit Card Type : Visa Card Master Card Amex Credit Card No. : Expired Date : January February March April May June July August September October November December ,2021 2022 2023 2024 2025 2026 Please describe your Spa Activity request in details :