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Online Forms

Roselle Center For Healing offers our patient form(s) online so they can be completed it in the convenience of your own home or office.

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  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s)to: 703-698-5729 or bring it with you to your appointment.


1. Notice of Privacy Practices (NPP) - Required

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

DOWNLOAD & PRINT FORM


2. New Patient Welcome & Office Policy - Required

This is patient information that we need to know and some initial history information.

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3. New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regardingwellness can we help you with? Let us know!

DOWNLOAD & PRINT FORM


4. Procedures and Policies Form - Required

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5. HIPAA Consent of Treatment Forms - Required

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6. Symptom Survey - Required

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7. Auto Accidents Form - Optional

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8. Nutritional Forms- Optional

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9. Personal Injury Forms - Optional

DOWNLOAD & PRINT FORM


10. FAQ About Medicare - Information

DOWNLOAD & PRINT INFORMATION


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Locations

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Office Hours

Our Regular Schedule

Fairfax Office

Monday:

7:00 am-6:00 pm

Tuesday:

2:00 pm-7:00 pm

Wednesday:

7:00 am-6:00 pm

Thursday:

2:00 pm-7:00 pm

Friday:

7:00 am-5:00 pm

Saturday:

8:00 am-1:00 pm

Sunday:

Closed