Patient 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!


New Patients: Please Print & Complete Before Your Session

ACT – NEW PATIENT HEALTH HISTORY

Email your completed forms to [email protected]; 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.

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-12:30 pm

3:00 pm-7:00 pm

Tuesday:

9:00 am-12:30 pm

3:00 pm-7:00 pm

Wednesday:

3:00 pm-7:00 pm

Thursday:

9:00 am-12:30 pm

3:00 pm-7:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed