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Lifestyle MOT Application
Helping you be healthy for the road ahead
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* Indicates required question
Email
*
Your email
Do you have any electronic device fitted? (pacemaker, Insulin, Pain, cochlear etc) If you answered yes, unfortunately treatment cannot be performed currently.
*
Yes
No
Name
*
Your answer
Phone number
*
Your answer
Location
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Place of Birth
*
Your answer
What is the biggest struggle you want to look at?
*
Your answer
Is there anything else you would like to ask or add?
Your answer
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