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2012
March
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First Name
:
*
Last Name
:
Address 1
:
Address 2
:
City
:
State
:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
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Iowa
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Maryland
Massachusetts
Michigan
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Mississippi
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Montana
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Nevada
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New Mexico
New York
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Ohio
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Rhode Island
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
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District of Columbia
Zip
:
*
Phone
:
*
Email Address
:
We offer classes on how to energize, heal, and detox your body. Please check all the options below that apply to you.
Yes, I would be interested in attending a class
Yes, I would be interested on a one on one session
Yes, I would like to host a class
How satisfied are you with the following:
Very Unsatisfied
Unsatisfied
Neutral
Satisfied
Very Satisfied
Energy levels
Eating habits
Emotional state
Are you currently using natural and/or organic options in your daily routine?
Yes
No
Would you like to subscribe to my upcoming newsletter about health & wellness?
Yes
No
This week how many times did you?
1 time
2 times
3 times
4 times
5 times
6 times
Meditate
Sleep 7+ hours
Physical activity
Stretch
Eat your veggies
Skip a meal
Nurture yourself
Take your vitamins
It was an honor meeting you today! Please leave any comments or questions that come to you now.
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