Patient Forms

New Patients: Please Print & Complete Before Your Session

ACT Wellness Center: New Patient Forms

New Patient Form (if using insurance)

New Patient Form (if paying directly)

New Pediatric Patient Form (Infant to 5 years old)

New Pediatric Patient Form (6 to 17 years old)

  • 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 fill out your paperwork on your phone or in the comfort of your own home and speed up the process in the office, you can complete your new patient paperwork by following the links above! 
  • 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, and the 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

Established Patient: Re-Evaluation Form

  • 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.


HIPAA (Print only if needed)

ACT – HIPAA NOTICE (Sept 2013; Revised 2017)

  • Please be sure to read our Patient Privacy Policies. These are for your reference only. You do not need to print these out or bring them to our office.


No Surprises Act and Good Faith Estimate

View the No Surprises Act Notice

  • For patients electing not to use insurance as payment for Chiropractic services; you have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. 


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

2846 Garber Way | Woodbridge, VA 22192

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