First Name

Last Name

Phone Number

DOB mm/dd/yy

Are you a new client to Midland Physiotherapy Mat Classes? Are you a new client to Midland Physiotherapy Mat Classes? Yes No

Preferable Class Time - Please select one or all if they suit you. Preferable Class Time - Please select one or all if they suit you. Monday 9am with Caris Monday 6pm with Anita Wednesday 5pm with Caitlin Thursday 6pm with Paige Thursday 7pm with Amy Friday 8am with Amy Saturday 8am with Paige/Iza