Pediatric Intake Form (Infant to 5 Years Old)



Previous Chiropractic Care
Were X-rays taken:

Please list any/all medications your child is taking at this time and precise dosage per day in mg. Please include prescription drugs, over the counter medications, and any vitamins and supplements.


 We are excited that you have chosen ACT Wellness Center to assist in the health and wellness needs of you and your family! Let us know if there is anything we can do to make you more comfortable. Please complete this form as much as possible so that we can provide the best possible care for your family.

Parent's Marital Status:


Other doctors seen for this condition:
Has your child ever had chiropractic care?
Are you satisfied with care received there?
Has your child consulted or does he/she regularly consult any of the following providers? (Check all that apply)
Are you satisfied with care received there?

The primary system in the body, which coordinates health, is the CENTRAL NERVE SYSTEM. The vertebrae (bones of the spinal column) surround and protect the delicate NERVE SYSTEM. Chiropractors are specialists trained in "early detection" of injury to the SPINE & NERVE SYSTEM. The information below will help us to see the types of PHYSICAL, CHEMICAL, & EMOTIONAL stresses your child has been subjected to and how they may relate to his/her present spinal, nerve, and health status.


Please mark all symptoms your child has ever had, even if they do not seem related to the current problem:


Social history while pregnant:

Did you:
Did you: Drink caffeine

Labor and Delivery:

Location of birth:
Birth Intervention:
Were there complications during delivery?


Does the baby prefer feeding on one side more than the other?
After feeding, does the baby frequently spit-up?
Food/Drink allergies, sensitivities, or intolerances:


Has your child ever suffered from the following spinal traumas?
Has your child ever been in a car accident?
Has your child ever had a bone fracture or joint dislocation?
Has your child had any other traumas not described above?
Does your child sleep through the night?

ACT Wellness Center ● 14111 Minnieville Rd. ● Woodbridge, VA 22193


Vaccination history:
Do you have any concerns with your child's diet?


Does your child have difficulty concentrating?

Please check which skills your child can perform in each section:


ACT Wellness Center ● 14111 Minnieville Rd. ● Woodbridge, VA 22193

If there is a need for dietary changes or nutrients, would you like to be informed?
If there is a need for specific exercises, would you like to be informed?
If there is a need for support in the emotional/stress area of health, would you like to be informed?
I would like my child to have the following benefits from ACT Wellness Center: (check all that apply)


This authorization also extends to all other doctors and office staff members and is intended to include radiographic examination at the doctor s discretion. I further authorize the minor to complete and sign any documents at ACT Wellness Center which are customarily completed and signed by patients at your practice as a condition to treatment, and such signature shall serve as my own. In no event shall my signature to any other such document have any effect on this consent form.

ACT Wellness Center ● 14111 Minnieville Rd. ● Woodbridge, VA 22193

Your First Visit...

I understand and agree that health and accident insurance policies are an arrangement between my insurance company and myself -- not between my insurance company and this office. I agree to pay my estimated patient responsibility and further understand that the estimated responsibility is neither a guarantee of payment by my insurance company, nor necessarily an accurate reflection of my actual responsibility as determined by my insurance company upon processing of my claims. In the event that my insurance company does not pay on my charges at the estimated rate or within a reasonable period of time, upon request of this office I will immediately pay the balance owing on my account unless otherwise agreed to in writing. I understand that an interest charge may appear on all accounts over 90 days. I further understand and agree, that if this office must take any action to collect an outstanding balance on my account, I will be responsible for payment and will reimburse this office for all costs of such collection efforts, including, but not limited to, all court costs and attorney fees. 

I authorize this office to release any medical information relating to my treatment to any insurance companies which may be responsible for paying benefits to me, and to any attorney s who may be representing me due to my condition, and to complete any usual and customary reports and forms at no charge to assist in collecting from my insurance companies, attorneys, or other payers.

Notice: Identity theft is a criminal act that may result in prosecution by the law. If medical treatment is obtainedusing a fraudulent identity, the potential exists for the medical records of the victim to become mixed with the medical history of the criminal who obtains the services. In order to reduce the risk of identity fraud we are requesting that you provide proof of your identity prior to treatment. We will request two (2) types of identification, one of which has been issued by a state or federal agency.

I have read, understood, and agree to the foregoing. The information which I have provided is true and complete tothe best of my knowledge.

As a result of my chiropractic care, I would like to... (Check all that apply)

If you wish to have a third person or chaperone present during your examination & treatment initial here:

ACT Wellness Center ● 14111 Minnieville Rd. ● Woodbridge, VA 22193



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.


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

ACT Wellness Center ● 14111 Minnieville Rd. ● Woodbridge, VA 22193

INFORMED CONSENT - Chiropractic Adjustments & Care

ACT Wellness Center, 14111 Minnieville Rd., Woodbridge VA 22193

Dr. Carmelo C.C.S.P., C.C.E.P.

Instructions: This document relates to your Informed Consent for care.

Please read carefully before signing.

General: I, the below-signed patient/individuals, have read this document and Care Plan in their entirety and understandthe potential benefits and risks of the Care which you are recommending. I understand that there may be other forms of care which I may wish or need to seek provided by other health care practitioners. I also understand that there may be significant risks of not seeking any care for my condition.

I understand that while the Care Plan lists you as the "Rendering Provider," at any moment, other associates or staff in your office with appropriate scopes of practice and training may need to provide the Recommended Care based on factors which are not necessarily within anyone's ability to predict. You have made it clear that every health care practitioner who is licensed under state law may have different scopes of practice relating diagnoses and treatment and that the licenses of the primary Rendering Provider are listed below.

I do not expect you to be able to anticipate and explain all risks and complications, or forms of treatment, and I wish to rely on you to exercise judgment within your scope of practice during the course of the Care Plan which you feel at the time based upon the facts known. I understand that in rare cases, underlying physical defects, deformities or pathologies may render me susceptible to injury. It is my responsibility to make known before and throughout the Care whether I am suffering from any latent pathological defects, illnesses, or deformities that would otherwise not come to your attention, as well as any pathological defects, illnesses, or deformities I may be experiencing.

Possible Risks of the Care; Alternatives

Chiropractic manipulation / adjustment. As with any healthcare procedure, I understand that there are certain complications, although rare, which may arise during chiropractic manipulation, and that those complications include: fractures, disc injuries, dislocations, muscle strain, Horner's syndrome, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel somestiffness and soreness following the first few days of treatment. I understand that fractures are rare occurrences and generally result from some underlying weakness of the bone. I also understand that stroke and other complications are also generally described as "rare."

X-Rays. I have been advised that x-rays can be hazardous to an unborn child. To the best of my knowledge. I am not


ACT Wellness Center ● 14111 Minnieville Rd. ● Woodbridge, VA 22193

Other Potential Alternatives. I understand that other treatment options for my condition may include: Self-administered, over-the-counter analgesics and rest; medical care with prescription drugs such as anti-inflammatories, muscle relaxants and painkillers; hospitalization with traction; and surgery.

Contraindications to Manipulation / Adjustment. I understand that you will not give me an adjustment / manipulation, x-rays, modalities, or therapies if you feel that such are contraindicated. In the event that the Care does not include such procedures, I have discussed all contraindications with you and fully understand them.

Definitions. "You" and "office" refer to any provider who renders care to me at the Location above. "Care" includes all care outlined in my Care Plan as well as any other care I receive from you in the future, including care related to other conditions.

Patient's Consent. I hereby request and consent to the performance of chiropractic adjustments and other procedures, including various modes of physical therapy and diagnostic X-rays, on me (or the patient named below, for whom I amlegally responsible) by the Doctor of Chiropractic named below and/or other licensed Doctors of Chiropractic or those working at the clinic or office who now or in the future treat me while employed by, working or associated with, or serving as a backup for the Doctor of Chiropractic named below.

I have thoroughly discussed and reviewed my recommended Care with you, as well as your examination, diagnoses, and thoughts regarding my condition, and also all of the information in this Informed Consent. I have had ample opportunity to explore other potential forms of care, have asked you all of the questions that I have, and have no additional questions and all my questions have been answered fully and satisfactorily. I voluntarily and knowingly elect to receive the recommended Care

ACT Wellness Center ● 14111 Minnieville Rd. ● Woodbridge, VA 22193


Insurance companies can be your best friend – or your worst enemy, particularly if you do not comply with their


Since every insurance plan has its own special requirements, it is impossible for us to be familiar with each and every plan. Therefore, we must look to you, the patient, to assume the responsibility of knowing what your insurance coverage is. As a courtesy, we verify your insurance coverage during your first week of care. We cannot predict what they may pay for a particular service and you are ultimately responsible for knowing your benefits, the patient is always responsible for payment for any services rendered.

Unfortunately if your insurance carrier makes a mistake, by providing you with the wrong information, they are protected by legal disclaimers. That means, if your health benefits are misquoted, the insurance company does not have to pay according to what was stated. That is why we highly recommend that you call customer service to ask them to explain your chiropractic benefits. The number is on the back of your insurance card. Only you, the policy holder, can affect how they choose to behave, because of the contractual relationship that exists between the two of you.

It should be pointed out that our contract for services is with you, the patient. We work for you; not for your insurance company. ACT Wellness Center provides the best services that we are capable of providing and expect that payment for those services be made as promptly as possible. It is important, therefore, for you to become an informed consumer relative to your insurance coverage. As always Co-pays and Co-insurances are due at the time of service. If the

information received by us, from your insurance company is ever incorrect, we will try our best to remedy the situation; however, the resultant bill is still your responsibility.

If your insurance company requires pre-certification or pre-authorization for any services, it is your responsibility to obtain the authorization and notify the doctor, as well as to provide ACT Wellness Center with the proper forms and tomonitor the number of approved visits. (Please contact your Primary Care Doctor's office if you have any questions about pre-certification. On most insurance cards there is a telephone number listed to call which can help you in understandingyour coverage and exactly what needs to be obtained for certain services.)

We will expect that you honor all financial agreements made with our office. If you find that you cannot fulfill your financial obligation, notify our office immediately so that new arrangements can be made. Insurance companies are expected to pay their portion within 45 days of claim submission. If they do not, we expect the patient to call the insurance company on our behalf to help get the claim paid. If an insurance company sends a check to your home, it should be brought or sent to our office as soon as possible. Please also bring in the attached explanation of benefits.We hope this clarifies our billing policy. If you have any further questions, please do not hesitate to ask. We are here for you, and it is our pleasure to be of service to you.

ACT Wellness Center ● 14111 Minnieville Rd. ● Woodbridge, VA 22193


Your understanding of our financial policies is an essential element of your care and treatment. We are committed to providing you with the best chiropractic care possible and have established our Financial Policies to achieve that goal. If you have any questions, please discuss them with our front office staff or supervisor. In accepting care, you agree to the following:

Fee Schedule

Consultation…………….…....................... N/C

Initial Exam/Computer Scan…….…......… $52.00-$144.10

Dynamic Exam/Computer Scan…… ... $53.50-$98.60

X-Rays (per view) .................................... $28.33-$33.00

Chiropractic Adjustment(s)………….....….. $55.00-$65.00

Cold Laser Session................................... $35.00

Cold Laser Package of 6 ......................... $170.00

Wellness/Corrective Adjustment Plans.... $125 - $500 per month

Intersegmental Traction.......................….... $30.00

Intersegmental Traction.......................….... $30.00

Electronic Muscle Stimulation……….………… $40.00

 As our patient, you are responsible for all authorizations/referrals needed to seek treatment in this office.

 Unless other arrangements have been made in advance by you, or your health insurance carrier, payment foroffice services are due at the time of service. We will accept VISA, MasterCard, Discover, cash or check. I acknowledge responsibility for my account and guarantee payment of all charges against the account.

 Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment.

 I understand that this chiropractic office will assist me with any information, necessary reports or forms needed for me to personally file for reimbursement from my carrier.

 We have made prior arrangements with certain insurers and other health plans to accept an assignment of benefits. We will bill those plans with which we have an agreement and will only require you to pay the co-pay/coinsurance/deductible at the time of service.

 If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send the claim for you on an unassigned basis. This means your insurer will send the payment directly to you. Therefore, all charges for your care and treatment are due at the time of service.

 All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be "not covered," or you do not have an authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services or referrals; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered.

 You must inform the office of all-insurance changes and authorization/referral requirements. In the event the office is not informed, you will be responsible for any charges denied.

 Past due accounts are subject to collection proceedings. All costs incurred including, but not limited to, collection fees, attorney fees and court fees shall be your responsibility in addition to the balance due this office.

 There is a service fee of $35.00 for all returned checks. Your insurance company does not cover this fee.

 I authorize ACT Wellness Center to release necessary information to my insurance carrier.

 I authorize ACT Wellness Center to accept assignment of benefit.

I understand that my Payer may not pay for all of my care, even services that the Office 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 the Office, including care which my Payer may determine is not medically

ACT Wellness Center ● 14111 Minnieville Rd. ● Woodbridge, VA 22193


This Notice briefly describes how medical information about you may be used and disclosed and how you can get access to this information. Please Review It Carefully. For a more complete description of such uses and disclosures, please refer to ACT's Posted Notice of Privacy Practices. Copies are available… just ask!

Our commitment here at ACT Wellness Center (ACT) is to serve our customers with professionalism and caring, beingsure at all times to protect the privacy and security of all Protected Health Information (PHI). We here at ACT are committed to obeying all Federal, State and Local laws and regulations regarding Privacy Policies. During the course of serving your interests it may be necessary to share information such as treatment, payment and healthcare operations with other Health Care Providers or Business Associated. For payment purposes, we do electronic billing; your information is protected by a firewall system. Your file is a personal record and will not be released without your signature.

With my consent, ACT may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to ACT's Notice of Privacy Practices for a more complete description ofsuch uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. ACT reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to ACT's Privacy Officer, Christina at 14111 Minnieville Rd., Woodbridge, VA 22193 / (703) 491-9355 / Fax: (703) 490-2298.

With my consent, ACT may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. Also, ACT may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patientstatements. ACT may e- mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements During treatment, if you feel the need for a private adjustment ACT can accommodate.

I have the right to request that ACT restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. As provided for by law, I may revoke this written authorization at any time. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, ACT may decline to provide treatment to me.

If you have any questions, comments or concerns regarding your Protected Health Information, feel free to contact our

Compliance Officer, Christina at (703) 491-9355.


"You May Refuse to Sign This Acknowledgement"

I have read, understand and received or reviewed a copy of the Notice of Privacy Policies for ACT Wellness Center. By

signing this form, I am consenting to ACT's use and disclosure of my PHI to carry out TPO.

ACT Wellness Center ● 14111 Minnieville Rd. ● Woodbridge, VA 22193

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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