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Practice Name

Cafe of Life Chiropractic

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Primary Location
2555 Collins Ave Suite C4
Miami Beach, FL 33140
Phone: 305-674-9321
Fax: 305-674-9186

Office Hours

DayMorningAfternoon
Monday9 - 12:303:30 - 7
TuesdayClosed4:30 - 6
Wednesday9 - 12:303:30 - 7
Thursday10 - 12:303:30 - 7
Friday9 - 1 pmClosed
SaturdayClosedClosed
SundayClosedClosed
Main Content

In order to provide you the best possible Chiropractic care, please complete this form. With this New Patient form you can provide us health details that will help us diagnose the true causes of your suffering and back pain.

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:

...

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Company Massage Day

Massage Tuesdays

Time slots for Massage

10 am - 11 am - 12 pm - 2 pm

Appointments only Please Call

Testimonial

Thanks for giving my son Daniel a hope in life. After been told by the neurologists that he was never going to talk or even walk. He is running and talking. Thanks Dr G

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

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Services

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

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Contact

Cafe of Life Chiropractic
2555 Collins Ave Suite C4
Miami Beach, FL 33140
Get Directions
 
  • Phone: 305-674-9321
  • Fax: 305-674-9186
  • Email Us
From:  To:  Get Directions
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Office Hours

DayMorningAfternoon
Monday9 - 12:303:30 - 7
TuesdayClosed4:30 - 6
Wednesday9 - 12:303:30 - 7
Thursday10 - 12:303:30 - 7
Friday9 - 1 pmClosed
SaturdayClosedClosed
SundayClosedClosed
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