Online Forms

Valley Chiropractic Clinic offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic office.

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

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!

Download & Print Form Word Doc


Financial Agreement- Required

Download & Print Form Word Doc


Functional Questionnaire:  Choose one or More of the following- Required

Low Back Disability questionnaire

Download and Print Form Word Doc

Neck Pain Questionnaire

Download and Print Form Word Doc

Shoulder Disability Questionnaire

Download and Print Form Word Doc

Headache Disability Questionnaire

Download and Print Form Word Doc


Informed Consent- Required

Download and Print Form Word Doc


PHI Use Disclosure - Required

Download & Print Form Word Doc


Accident Report- Required for Auto Accidents

Download & Print Form Word Doc


PI Payments- Required for Auto Accidents

Download & Print Form Word Doc


Privacy Acknowledgement- Required

Download & Print Form Word Doc


Privacy Practices- For your information only

Please contact our office for brochure