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Wellness Intake Form
Tell Me a Little Bit about Yourself
Are you taking any medications?
If yes, please list name and use:
How many continents are there?
Who was the first man to go into space?
Where is Budapest?
Which of these is a prime number?

Thanks for submitting!

To inspire people to be happy, healthy, and empowered to live the best life at any age.

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The goal at Mind Body Solutions is to feel optimal results in feeling good!

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Serving Central Florida Areas of Mount Dora, Eustis, Tavares, and surrounding areas. 

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Located at:

1416 N. Donnelly Street Suite #4

Mount Dora, FL 32757

352-636-9932

© 2023 Mind Body Solutions • Jan Cloutier, LMT MA 56464

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