Patient Forms

We want to make your visit to as pleasant as possible. We ask that you arrive 30 minutes prior to your scheduled appointment time. To speed up the process you can download and fill out our new patient forms listed below.

New Patients: Please Print & Complete Before Your Session

ACT – NEW PATIENT HEALTH HISTORY

24 hours prior to your appointment, we will need to collect some basic information to coordinate pre-verification. Please send us a copy of your valid ID, your completed new patient intake form and front and back of your insurance card (if applicable). Email all items to [email protected]

Remember bring your photo ID and insurance card--if using insurance--to your appointment.

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

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.


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 What Can I Expect?.

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Our Location

14111 Minnieville Road | Woodbridge, VA 22193

Office Hours

Our General Schedule

Monday:

9:00 am-12:00 pm

3:00 pm-6:30 pm

Tuesday:

9:00 am-12:00 pm

3:00 pm-6:00 pm

Wednesday:

3:00 pm-6:00 pm

Thursday:

9:00 am-12:00 pm

3:00 pm-6:30 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed