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Practice Name

Richmond Family Chiropractic

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Primary Location
164 Main Street Unit 3
Richmond, ME 04357
Phone: (207) 737-2482
Fax: (207) 737-2484

Office Hours

DayMorningAfternoon
Monday9:00 - 11:00am2:30 - 6pm
Tuesday9:00 - 11:00am2:30 - 6pm
Wednesday9:00 - 11:00am2:30 - 6pm
Thursday9:00 - 11:00am2:30 - 6pm
FridayClosedClosed
SaturdayClosedClosed
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:

Request an Appointment Today!

Sign-up using the form or call us at (207) 737-2482 to request an appointment.

Name: *
Email: *
Phone: *

Our Services

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

I'm very happy I have begun treatments with Dr. Jeff and Hedy - both are awesome. Thank you!

- Marla B. / Richmond, ME

Office Hours

DayMorningAfternoon
Monday9:00 - 11:00am2:30 - 6pm
Tuesday9:00 - 11:00am2:30 - 6pm
Wednesday9:00 - 11:00am2:30 - 6pm
Thursday9:00 - 11:00am2:30 - 6pm
FridayClosedClosed
SaturdayClosedClosed
SundayClosedClosed

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Contact

Richmond Family Chiropractic
164 Main Street Unit 3
Richmond, ME 04357
Get Directions
  • Phone: (207) 737-2482
  • Fax: (207) 737-2484
  • Email Us
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