Coming soon to Arlington & Tyson's Corner

acupuncture | chiropractic | massage | medicine | nutrition

physical therapy psychotherapy | sports medicine

All Patients

Please print & fill out the General Intake Form and other pertinent forms below.  Email (wellness.analyst@skylinewellnesscenter.com) or fax (703.879.5860) to our office, including a copy of your driver's license and insurance card within 24 hours of setting your appointment.  It will allow us time to verify insurance before you come for your visit.  If you do not have access to a printer or fax, you can fill out the forms at the office before your appointment.  Please come 15 minutes early so you can work on them.  

All Patients

Forms to Review & Sign:

General Intake Form

Insurance Verification

Forms to Review Only:

HIPAA Notice of Privacy Practices 

Financial Policy | Cancellation & Rescheduling Policy

Only if Applicable:

Application for Financial Assistance

ChiroHealth USA

Consent to Treat a Minor

Orthotics Promotion Agreement

Authorization to Release Records to a Third Party

Records Request to SWC

Record Request from SWC

Patient Election to Self-Pay for Services


Chiropractic

Forms to Review & Sign:

Chiropractic Informed Consent to Treat

Only if Applicable:

Personal Injury Accident

ASH Initial Status

ASH Progress Report

Optum Health

Employment Injury Accident

MAG-7

Re-exam Questionnaire

Returning Patient Questionnaire

Waiver of X-Ray Exam

Neck Pain Disability Index

Low Back pain Disability Index


Acupuncture

Forms to Review & Sign:

Acupuncture Informed Consent to Treat

Arbitration Agreement


Massage

Forms to Review & Sign:

Massage Therapy Informed Consent to Treat

Only if Applicable:

Massage Therapy Membership Agreement


Sports Medicine

Only if Applicable:

Movement Coaching Membership Agreement