Integrative Medicine | Holistic Healthcare

Integrative Medicine | Holistic Healthcare – Start Your Healing Here

INTEGRATIVE Family MEDICINE Center
Mind-Body Therapeutic Massage Nutrition Acupuncture

116-Q Edwards Ferry Rd, NE
Leesburg, VA 20176
(703) 669-6118

Patient Forms

IFMC No Show / Cancellation Policy

Thank you so much for choosing us for your Healthcare needs. We are always glad to make
appointments for you, and we appreciate your support of Integrative Medicine.

Our policy is to charge you $100 for missed appointments or canceling with less than 24 hour notice.
A late cancellation prevents us from offering this time to someone in need.

If the office is not open, you may always leave a message requesting a cancellation or rescheduling…
we thank you for respecting our time, and our goal of accessible Integrative health services.

The following forms are available in two formats: Microsoft Word or Adobe PDF.
To view and print a form, click on the corresponding link above and the page will open a new browser window.
To return to this page, simply close the new window.


Adult Medical Questionnaire /uploads/ADULTMEDICALQUESTIONNAIRE.doc


Records Release Form MS Word Adobe PDF


Privacy Notice MS Word Adobe PDF


Women's Confidential Health History (NUTRITION VISITS ONLY) MS Word Adobe PDF


Men's Confidential Health History (NUTRITION VISITS ONLY) MS Word Adobe PDF


Pediatric Patient Form MS Word Adobe PDF

Patient-Centered Medicine

Comprehensive Healthcare

Traditional and
Complementary Therapies

A Whole-Body Approach
to Health & Well-being

Affiliated with: