Optimal Health and Wellness

Class (select one): *

Birth to 6 months (2 to 3 p.m.)

6 to 8 months (11 a.m. to noon)

8 to 14 months (9 to 10 a.m.)

14 to 24 months (10 to 11 a.m.)

24 to 36 months (3 to 4 p.m.)

Parent Name: *

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Child's Name *

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Child's date of birth: *

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Email: *

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Phone Number: *

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What are you most interested in gaining from the class? *

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Do you have any concerns about your child’s development? *

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Will you have additional children in attendance? Age(s)? *

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Are you a current patient at Optimal Health and Wellness? *

Your answer

Are you interested in learning more about chiropractic care? *

Your answer