WARNING

You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]

Call Us Today

907-373-2022
m

907-373-2022. 400 N Main St Wasilla
Get Direction

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



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 chiropractic office. You can print the form out and bring it in to our office during your next visit with our chiropractor, 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!

Download & Print Form



 

Services
We strive to provide complete care for our patients. Learn more about all the services we provide.
Make An Appointment
We will do our best to accommodate your busy schedule. Schedule an appointment today!
Online Forms
Our patient forms are available online so they can be completed in the convenience of your own home or office