Adult Intake Form (Insurance)

Welcome to our office!

Thank you for choosing ACT Wellness Center. As a full spectrum Chiropractic office, we focus on your ability to be healthy. Our goals are, first, to address the issues that brought you to this office, and second, to offer you and your family the opportunity of improved health potential and wellness services in the future. We will be working together to help you and your family reach your health and wellness goals. We will conduct a thorough history and physical examination to decide if we can assist you. Answering the following questions will give us a profile of the specific stresses you have faced in your lifetime, allowing us to better access the challenges to your health potential. If we do not believe that your condition will respond to chiropractic care, we will not accept you as a patient but will refer you to another health care provider, if appropriate.

If you ever have any questions about your chiropractic care, please don't hesitate to ask one of our highly educated chiropractic team members. All of your questions, even the ones you haven't even thought of yet, will be answered during your Chiropractic Report.

About this Patient

About the Spouse 

Employer Information

Reason for this Visit

Is the purpose of this appointment related to:*
Please select one option

Place an X X X on the image below, where you feel pain. 

Place an / / / on the image below, where you feel stabbing.

Pace an O O O on the image below, where you feel numbness.

Mark your Pain Point

Experience with Chiropractic 

Awareness of Chiropractic Principles 
Were you aware that...

Doctors of Chiropractic work with the nervous system?*
Please select one option
The nervous system controls all bodily functions and systems?*
Please select at least one option
Chiropractic is the largest natural healing profession in the world?*
Please select one option
If Chiropractic care starts at birth, you can achieve a higher level of health throughout life?*
Please select at least one option

Goals for my Care

People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of their pain, and others for correction of whatever is malfunctioning in their bodies. Your Doctor will weigh your needs and desires when recommending your treatment program.

Please check the type of care desired so that we may be guided by your wishes whenever possible.

Health Habits & Conditions

Medications I Now Take:
Do you exercise regularly?*
Please select one option
Do you wear:
Health Conditions:


Authorization for Care / Terms of Acceptance

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be able to attain it. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxations. Our chiropractic method of correction is by specific adjustments of the spine.

Health: A state of optimal physical, mental and social well being, not merely the absence of disease or infirmity.

Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.

I have read and fully understand the above statements. I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate. I therefore accept chiropractic care on this basis.

I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

Who should receive bills for payment on your account?*
Please select at least one option

Ownership of X-ray Films

It is understood and agreed that the payments to the Doctor for X-rays is for the examination of X-rays only. The X-ray negatives will remain the property of this office. They are kept on file where they may be seen at any time while I am a patient of this office.

Emergency Contact

My Health Insurance

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself . I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.


I understand that my Payer may not pay for all of my care, even services that the ACT Wellness Center deems medically necessary. I agree that I will be responsible for verifying and understanding my own coverage and benefits. Right now, it appears that the following items or services may not be covered. I understand that there may be other items or services that are not covered and that if I have any questions, I will contact my Payer for more details. I agree that I am personally and fully responsible for all services rendered by ACT Wellness Center, including care which my Payer may determine is not medically necessary.

By signing this document, I authorize and direct that payment be made directly to: ACT Wellness Center / Dr. C.C.S.P., C.C.E.P.,
14111 Minnieville Rd., Woodbridge VA. 22193. For any and all insurance benefits or reimbursement for services rendered by him which amounts would otherwise be payable to me under any insurance or pre-paid health care plan.

RELEASE OF INFORMATION: By signing this document, I authorize the release of any information concerning my health and health care services to my insurance companies, pre-paid health plan of Medicare.


Nutrition and self-care are just two of the components in obtaining optimal wellness. 

Please let us know what you are currently doing for your health.

Things I do currently to support my health include:
Please indicate which of these you do/have on a consistent basis:

Initial Consultation Form 

Overall frequency of complaint ( choose one)
Overall intensity of complaint (choose one)
If yes, please select the amount below that you feel your symptoms increase at work:

Missed Appointments 

We strive to provide you with the utmost professionalism and excellence of service. Our commitment to your well-being and health is something we take seriously.

We care about you and realize it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need and to the actions we recommend to you.

  • Your faithfulness to the recommended number of adjustments is key to ensuring optimum results.
  • With the exception of emergencies, it is vital that you keep all your appointments. Reminder cards are provided to help you save the date. If you need to re-schedule an appointment, please call our office and arrange for a make-up appointment with our chiropractic assistants. We would prefer the make up appointment to be within the same week.
  • In the instance of a no show without notice by phone we reserve the right to charge you a $20.00 fee.

Thank you for your understanding. We greatly appreciate you as our patient and strongly desire excellent results and success for you!

I understand and agree to all the information written above.

Office Fee Schedule and Financial Policy 

 Service                                                           Fee 

ConsultationNo Charge
Initial Exam/Computer Scans$52 - $144.10
Dynamic Re-Exam/Computer Scans      $53.50 - $98.60
X-Rays (Per View) $28.33 - $33
Chiropractic Adjustments$55 - $65
Wellness Adjustment Plans $125 - $500 per month
Cold Laser Session$35
Cold Laser Package of 6$170
Intersegmental Traction$30
Electronic Muscle Stim$40

Our experience has shown that it is wise to have an understanding with our clients as to our office policies and fees. Therefore, this form has been prepared for your convenience and information. We offer several methods of payment for your care at our office and you may choose the plan that you prefer. This information will enable us to better serve you and help to avoid misunderstandings in the future. Our main concern is your health and well being and w will do our best to help you.

Important: All clients are responsible for full payment for the first visit (unless other arrangements have been made in advance.)

Today's payment will be made by:*
Please select at least one option


We will verify all insurances and your benefits per your agreement with your carrier. After verification the Doctor will give his recommendations and an appropriate plan will be designed for each individual. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately. 


My signature below signifies my agreement for payment in full on a cash basis if I have not provided all the necessary documents and information by the time of the second visit.

I have read and agree to the above statement.

Thank you for taking the time to fill out this form.

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Our Location

2846 Garber Way | Woodbridge, VA 22192

Office Hours

Our General Schedule


9:00 am-12:00 pm

3:00 pm-6:30 pm


9:00 am-12:00 pm

3:00 pm-6:00 pm


3:00 pm-6:00 pm


9:00 am-12:00 pm

3:00 pm-6:30 pm