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925 Commercial St. Suite 260 Salem, OR 97302

Heppner Chiropractic offers our patient forms online so they can be completed in the convenience of your own home or office. If you would prefer to complete your forms electronically, click here to request a copy be sent to your email.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Download the necessary forms, print them out and fill in the required information.
  • Bring your completed forms with you to your appointment.

New Patient Health History Forms - Required for all New Patients

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 Forms

Consent Form  / Notice of Privacy Practices - All New Patients

This gives consent to our office policies as well as to our private practices (HIPAA).  You are welcome to view our privacy practices here and sign / initial the consent form (below) before you come. If you have any questions or concerns about these policies, please save this form for your first visit where your questions can be answered by our staff before giving your consent.

Download & Print Forms

If this prints too tiny, you may need to adjust your print settings to print 1 image per page.

Auto Injury Form  (If applicable)

This gives us details about your Auto Injury if you would like us to open a Personal Injury claim for you.  Please fill this out in addition to the regular new patient paperwork.  We will also need you to bring all the information you have regarding your claim # and the address to which we'll send claims.   We do not accept Work Injury Cases at this time. 

Download and Print Forms

If this prints too tiny, you may need to adjust your print settings to print 1 image per page.

Member Wellness Registration - Optional

In order to have full access to the member wellness section of our website, you'll need to register as a website member.   Click Here to register online!  You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office.  The online newsletter sign-up is also available online.  You can register by clicking the buttons at the bottom of this page. We look forward to making your experience with our office and website more interactive and rewarding!

PHI Patient Authorization for Disclosure of Protected Health Information

Download and Print Forms

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