Request An Appointment

Note: This form is NOT for people needing urgent medical care. For medical emergencies, call 911 or go immediately to the nearest emergency room.

Fields marked by an * are required.

Main Contact Person:
*Daytime Phone:
Alternative Phone:
*Mailing Address:
*City:
*State:
*Zip:
Country:
*E-mail Address:

*Appointment is for:
*Patient First Name:
*Patient Last Name:
*Patient Date of Birth:
*What is condition or treatment desired?
How Soon Do You Want to See Doctor?
*Health Insurance?
How Did You Find Douglas Chiropractic?

Douglas Chiropractic
4140 N W 12th Street
Lauderhill, Florida 33313
Office Number: 954-739-3331
Fax : 954-792-4520
E-mail: douglascc@bellsouth.net

Rapid Rehab
8910 Miramar Parkway, Suite 115
Miramar, Florida 33025
Fax: 954-443-8445
Email: rapidrehabcs@bellsouth.net