contact us
703-642-7522
Annandale Office
4208 Evergreen Lane, Suite 213
Annandale, VA 22003
Alexandria Office
5148 Leesburg Pike
Alexandria, VA 22302
Falls Church Office
7655 Leesburg Pike
Falls Church, VA 22043
Fairfax Office
3925 Blenheim Blvd, Unit 52 #C/D
Fairfax, VA 22030
Merrifield Office
2810 Old Lee Hwy STE 305
Fairfax, VA 22031
Reston Office
1892 Preston White Dr, Ste 201
Reston, VA 20191
Patient Forms
Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.
Patient Forms
Authorization for Release of Medical Information (PDF) – Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente
Authorization and Consent for Treatment (PDF) – All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento
Preferred Contacts (PDF) – Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos
Virtual Visit Policy (PDF) – This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.
Language Services (PDF) – Information on available language assistance services, including interpreter support, to help patients communicate effectively with their care team.
Office Policies
Financial Policy (PDF) – This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)
Notice of Privacy Practices (PDF) – Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad (PDF)