Office (703) 385-7007

Patriot Chiropractic Center   

Dr. Steven Bernabeu & Dr. Gina Simonetti

New Patients:

Do not let filling out paperwork get in the way of a great appointment! Please complete and bring with you the first five documents and consent to treatment of a minor if applicable. If you are unable to print the forms, please arrive 15 minutes before your scheduled appointment  time to complete them in office. 


Note: printing from web browser may distort documents, please download and print for best results

New Patient Forms:

- Patient Registration  (download)
- Patient Case History (download)
- HIPPA Notice of Privacy Practices  (download) 
- Office Policy (download)
- Consent to Email and/or Text    (download)

- Consent to Treatment of a Minor    (download)


Existing Patient Forms:

- Medical Records Release    (download)

- Update Contact Information (download)


Nutritional Forms:

- Nutritional Assessment (download)