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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 FREE ADOBE READER®
  • 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.

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2. New Patient Information Form - 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, regarding wellness can we help you with? Let us know!

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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

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10. Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!

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11. FAQ About Medicare - Information

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Roselle Center for Healing

THIS ---->https://rosellecare.chiromatrixbase.com/online-forms.html

Office Hours

Day
Monday7:00am6:00pm
Tuesday2:00pm7:00pm
Wednesday7:00am6:00pm
Thursday2:00pm7:00pm
Friday7:00am5:00pm
Saturday8:00am1:00pm
SundayClosedClosed
Day
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
7:00am 2:00pm 7:00am 2:00pm 7:00am 8:00am Closed
6:00pm 7:00pm 6:00pm 7:00pm 5:00pm 1:00pm Closed

Testimonial

I highly recommend the Roselle Center for Healing for anyone with a chronic disease or seeking to improve their health.

After meeting Dr. Tom Roselle, DC at a Town Hall meeting, I made an appointment for a spinal cord/brain injury that resulted in Autonomic Dysfunction (POTS).

For the last ten years, I was fainting/passing out many times a day, had liable blood pressure, gastroparesis, neuropathy and severe pain.

My first appointment was with Dr. Tom Roselle, DC. His understanding of dysfunction of the body and its causes are exceptional. He took the time that was needed, explained the diagnosis and treatment plan in detail. I also saw Dr. Scott Lamp, Sue Roselle for nutrition, and Dr. Stephanie Pina for acupuncture-all very knowledgeable. The staff is welcoming and professional. The waiting room is calm and comfortable.

My health has significantly improved because of the Roselle Center for Healing. I was bedridden. I no longer pass out. I needed IV's and now I can eat and enjoy food. I used a walker and now I walk unaided. This past weekend, I hiked four miles!  My many thanks to the Roselle Center for Healing-you have changed my life!

Sandra E., Fairfax, Virginia

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