Switch to Main Site
Practice Name

Homestead Chiropractic Clinic

Social Media
Primary Location
125 NE 8th St Ste 3
Homestead, FL 33030
Phone: 305-247-2804
Fax: 305-247-9471

Office Hours

DayMorningAfternoon
Monday8 - 122 - 6
Tuesday8 - 122 - 6
Wednesday8 - 122 - 6
ThursdayClosedClosed
Friday8 - 122 - 6
SaturdayBy Appt.Closed
SundayClosedClosed
Main Content

In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

Follow Us

Request an Appointment

We will do our best to accommodate your busy schedule. Request an appointment today!

Schedule Now

Services

We strive to provide complete care for our patients. Learn more about all the services we provide.

Read More

Contact

Homestead Chiropractic Clinic
125 NE 8th St Ste 3
Homestead, FL 33030
Get Directions
 
  • Phone: 305-247-2804
  • Fax: 305-247-9471
  • Email Us

Office Hours

DayMorningAfternoon
Monday8 - 122 - 6
Tuesday8 - 122 - 6
Wednesday8 - 122 - 6
ThursdayClosedClosed
Friday8 - 122 - 6
SaturdayBy Appt.Closed
SundayClosedClosed
Newsletter

Newsletter Sign Up










Community Content