807 North Monte Vista Street Ada, OK 74820
Phone : 580-332-8855     |     Fax: 580-332-7374
Hours : Monday-Friday 8:30 a.m. - 5:00 p.m.
Forms
Authorization for Release of Medical Information
If you are needing any of your health records we need this authorization filled out BEFORE we can release ANY information to you.


Patients Information/Disclosure Agreement
If you have not been seen in over a year please fill this out PRIOR to your appointment. We have to have an updated form yearly. If anything has changed, please contact our office to let them know.


ACOG-FORM A- FRONT

 Please fill this form out PRIOR to your New Ob visit at our office.



ACOG-FORM B-BACK
Please fill this form out PRIOR to your New OB visit at our office.


Minor Release Form
Any persons under the age of 18 that will not been seen with their parent/guardian needs to have this filled out PRIOR to being seen at their appointment at our office.

Patient History- Becky Ross
If you are seeing Qiong Mu (Becky) Ross for Adult Medicine we ask you fill this form out PRIOR to your appointment.