820 NW 13th Street
Oklahoma City, OK73106
2313 S. I-35 Service Road
Request an Appointment
Please bring the following items with you to your appointment:
• Valid Photo ID
• Insurance Cards
• Previous medical records and MRI reports associated with your pain condition.
On your initial consultation we will perform an evaluation and assess your medical condition. Boxes marked with a red * are required.
YOU WILL SEE A "SUBMITTED" MESSAGE AFTER YOUR PRESS THE "SUBMIT" BUTTON AT THE END OF THE FORM. Thank you for choosing The Brooks Accident & Injury Clinic.
If yes, please give dates.
I acknowledge that The Brooks Accident & Injury Clinic can send me text messages or email of my appointment reminders
Please include City
Mark All That Apply
If answer is YES please bring your list to your exam. If answer is NO, please enter your medications in the space below.
Please check any medical conditions and indicate the family member associated: Self / Mother / Father
I acknowledge that this electronic signature represents my true signature and will be used throughout this patient information form. Anywhere I type my name, I intend this to be my legally binding signature.
If referred by a doctor or medical facility, please give name
If referred by an Attorney, please give name
Learn more about your health in our blog. We have put together useful articles to help you understand your condition and tips to help you get better.