Medical Forms

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The Warren Clinic Release of Medical Information form can be used to request a copy of your medical records for legal reasons or to transfer records to another physician. You can print a copy of the form and mail, fax or drop this form off at your Warren Clinic physician's office. The physician can not release your medical records without your written consent unless required by court order.

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  • Authorization for Emergency Care to Minor(s) The Authorization for Emergency Care to Minors should be printed, completed and signed by a parent/legal guardian. This form is authorization by the parent/legal guardian for any medical facility to provide health services to the minor in the absence of a parent/legal guardian. This form should be left with the temporary caregiver of your child. The temporary caregiver will be required to present this form at the time medical care is received. For example, if your child is visiting Grandma and Grandpa this summer, you will want to print, complete and sign this form and leave with Grandma and Grandpa. This will enable them to seek medical care for your child in the event it is necessary. You may also want to leave this form with your summer babysitter, your child's day care facility or the counselor at your child's summer camp. The form is valid throughout Oklahoma. You may make additional copies if necessary.
  • Authorization for Release of Medical Information The Warren Clinic release of medical information can be used to request a copy of your medical records for legal reason or to transfer records to another physician. You can mail, fax or drop this form off at your Warren Clinic physician's office. The physician can not release your medical records without your written consent unless required by court order.
  • Authorization for Treatment to Minor(s) The Authorization to Treat Minor(s) form authorizes Warren Clinic to provide medical services to your child in the absence of a parent/legal guardian when they are in a Warren Clinic facility. The form should be printed, completed, signed and given to your child's Warren Clinic physician's office. The form will be kept in your child's medical record and will remain valid until consent is revoked in writing or when your child may legally consent for themselves. Consider adding this form to your child's medical record if you have a grandparent take your child to a doctor's visit, an older sibling take his brother/sister to a doctor's visit or have your child's babysitter take him in for his weekly allergy shot for example.
  • Advance Directive This form is provided to serve as a framework for individuals who wish to complete an Advance Directive, also known as a living will.

    Medical treatment decisions may need to be made at a time when the patient is no longer mentally able to make a decision. Individuals may express their wishes ("directives") in advance in writing concerning the types of medical treatment they want or do not want, including life-sustaining treatment. This document is known as an Advance Directive, and may be followed under certain conditions, if patients are no longer able to make decisions.

    In order for doctors or hospital workers to be legally required to follow an Advance Directive, it must meet certain requirements. Individuals must be at least 18 when signing an Advance Directive and of sound mind. It must be signed by the individual and the signature witnessed by two persons. Heirs, legatees or devisees (persons with an interest in the estate of the individual) are not permitted to be witnesses.

    The instructions or directives in an Advance Directive should be followed by the doctors, hospital workers and family when the individual is certified to have reached the specified medical condition. The Advance Directive form has options for activation of the directives upon the individual attaining a "terminal condition" or a condition of "persistent unconsciousness." Individuals also have the option to specify activation of directives if they reach an "end stage condition" or some other condition that is affirmatively specified.

    Finally, Oklahoma law presumes that patients wish to be tube-fed if they can no longer take food and water by normal means. Those who do not want to be tube-fed under certain medical conditions, must set forth in their Advance Directive that no artificially administered nutrition or hydration be done. As a Catholic health care provider, Saint Francis Health System facilities will honor the Advance Directive unless it conflicts with Catholic Ethical and Religious Directives. For instance, our hospitals may not be able to participate in directives that include dehydration or starvation for the ending of life. Transfer can be arranged as needed. The Saint Francis Institutional Ethics Committee can be consulted for more assistance.
  • Directiva Avanzada Este formulario se proporciona como un marco de trabajo para aquellos individuos que deseen completar una Directiva Avanzada, conocida también con el nombre de Testamento en Vida.

    En ciertas ocasiones, podría ser necesario tomar decisiones respecto del tratamiento médico en un momento en el que el paciente ya no tiene la capacidad mental para tomar decisiones. Las personas pueden expresar, de antemano y por escrito, sus deseos ("directivas") sobre los tipos de tratamientos médicos que quieren o no quieren recibir, incluyendo el tratamiento para mantener a pacientes con vida. Este documento recibe el nombre de Directiva Avanzada, y puede respetarse y seguirse bajo ciertas condiciones si los pacientes ya no tienen la capacidad para tomar decisiones.

    Para que los médicos o trabajadores del hospital tengan obligación legal de seguir las indicaciones de la Directiva Avanzada, ésta debe cumplir con ciertos requisitos. Los individuos deben tener por lo menos 18 años de edad al momento de firmar la Directiva Avanzada y tener plenas capacidades mentales. El documento debe estar firmado por la persona y, al momento de la firma, debe haber dos testigos presentes. No se permite que herederos, legatarios o sucesores (personas con un interés en la masa hereditaria del individuo) actúen como testigos.

    Los médicos, trabajadores del hospital y familiares deben seguir las instrucciones o directivas que figuran en una Directiva Avanzada cuando se haya certificado que el individuo se encuentra en la condición médica especificada. En el formulario de Directiva Avanzada hay opciones para la entrada en vigencia de las directivas en caso de que el individuo sufra una "enfermedad terminal" o se encuentre en estado de "inconsciencia permanente". Los pacientes también tienen la opción de especificar la entrada en efecto de las directivas si sufren una "condición de etapa final" o alguna otra condición que se especifique de manera positiva.

    Para terminar, la ley del estado de Oklahoma presume que los pacientes desean ser alimentados por sonda si ya no pueden comer o beber por los medios normales. Aquellas personas que no deseen recibir alimentación por sonda bajo ciertas condiciones médicas, deben indicar en su Directiva Avanzada que no se realice ningún tipo de administración artificial de nutrición e hidratación. Como proveedores católicos del cuidado de la salud, las instalaciones del Sistema de Salud Saint Francis (Saint Francis Health System) respetarán la Directiva Avanzada a menos que ésta entre en conflicto con las Directivas Éticas y Religiosas del Catolicismo. Por ejemplo, nuestros hospitales tal vez no puedan participar en directivas que incluyen la deshidratación o inanición para la finalización de la vida. Se pueden hacer arreglos para transferir al paciente cuando esto fuera necesario. Para recibir más asistencia, puede consultarse al Comité de Ética Institucional de Saint Francis.

  • Patient Registration The patient registration form can be printed, filled out and brought to your first appointment with a Warren Clinic physician. This form is provided to help expedite some of the paperwork on your first visit.
  • The Medical History (Adult Medical Profile) - (Perfil Medico de Adultos) forms can organize your medical history and current symptoms to help us provide you with the best possible care. The most important first step for the diagnosis and treatment of any ailments is a complete and accurate medical history. Your physician's or provider's office may ask you to print out these forms, complete them, and bring them to your first visit. If you have other medical records in your possession, please check with the office to learn whether you should bring copies of those other records to your visit.
  • The Review of Systems form allows you to answer specific questions about each body organ system. Your physician may ask you to print this form, fill it out and bring it in to your comprehensive or annual examination. Please be sure to check an answer to each question. If a particular symptom is not constant and only occurs occasionally, you can check the "Occ" box rather than the "Yes" box.
  • The New Patient Comprehensive History Questionnaire is used by some of the physicians in Warren Clinic. Please use this form only if requested. If you are not asked to use this form, please use the Medical History (Adult Medical Profile) form instead. The New Patient Comprehensive History Questionnaire is more detailed and not needed for all new patients.
  • Our form Let's talk about your annual physical and insurance benefits will guide you through the differences between physicals done to promote wellness and prevent disease, and physicals done to monitor the progress of chronic medical conditions. Your physician or provider may ask you to complete this form to help decide the type of examination you should have. This information will help us properly process your insurance claims. Benefits for preventive services vary considerably among insurance companies. You may want to check your benefits before your visit.