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:

ACT – NEW PATIENT HEALTH HISTORY

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)

Please be sure to read our Patient Privacy Policies.

ACT – HIPAA NOTICE (Sept 2013; Revised 2017)

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 QUESTIONAIRE

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

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 9 consecutive years

Sign up for our newsletter!

Join our mailing list to receive the latest news and updates.

You have Successfully Subscribed!