Forms

We want to make your visit to ACT Wellness Center as pleasant as possible. On Your First Visit, we ask that you arrive 30 minutes prior to your scheduled appointment time to fill out necessary paperwork. To speed up the process you can download and fill out our new patient forms listed below, so you may arrive 15 minutes prior to your scheduled appointment time. This is only a one-time requirement and in order to save you time, we offer them right here for you!

Please Print & Complete Before Your Session:

New Patient Intake Form

Email your completed forms to: info@actwellness.com; fax forms to 703-491-2298 or bring them with you to your appointment. Please bring your photo ID and insurance card, if using insurance, to your appointment.

HIPAA (Print only if needed)

You may also use this form to designate who we can disclose your personal health information to

ACT – HIPAA Notice Privacy Practices (Sept 2013)

Please be sure to read our Patient Privacy Policies.

ACT – HIPAA Authorization for Disclosure Form (Sept 13)

If you do not already have Adobe Reader® installed on your computer, Click Here to download.

For Established Patients Only

For every 12 visits in which you are a patient at ACT Wellness Center, we want to monitor how well your overall health has improved. Complete the Re-Evaluation Questionnaire form so we will be able to track your health improvement progress over time.

ACT Re-Evaluation Questionnaire

Cancellation Policy
If you need to cancel an appointment or change the time or date please call as soon as possible. There may be a charge for missed appointments or those cancelled with less than 24 hours notice if we are unable to fill your time slot from our waiting list.

Should you have questions about the forms, please contact our knowledgeable staff for assistance at 703-491-9355. To get an overview of what happens next check out Your First Visit.

Success Stories from Our Patients

  • Improved Health

    When I first came to Dr. C’s office, I had tension in my upper back that moved to the lower part of my skull. After receiving chiropractic care for one month, that tension was relieved. I was also very surprised when I got a cold that it lasted only a week. During the fall allergy season I usually have to battle off bronchitis or pneumonia since I have asthma.

    – Rita W
  • Pain Free in so many ways

    I’ve been under chiropractic care for a very long time. All I can say is, the care has kept me going, helped me stay pain free in so many ways. Plus, the positive atmosphere and encouragement plays a tremendous part in staying with the program.

    Thank you, Dr. C and you staff for all your help and support. You are the best!

    – Diane W.
  • I am happy!

    I’ve been in pain for years – upper left back, neck, and excruciating lower back / buttock pain.

    Chiropractic has Changed My Life by: Reduced pain, excellent sleep – I’m happy.

    – David G.

    Call (703) 491-9355 or Schedule an Appointment Today

    Act Wellness

    Your Woodbridge Chiropractor

    14111 Minnieville Road,
    Woodbridge, VA 22193

    (703) 491-9355

    Fax 703-490-2298

    Dr.C@actwellness.com

    Office Hours

    Monday • 9:00-12:30 | 3:00-7:00
    Tuesday • 9:00-12:30 | 3:00-7:00
    Wednesday • 3:00-7:00
    Thursday • 9:00-12:30 | 3:00-7:00

    Voted Best Chiropractor for 8 consecutive years

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