Chief Gary Batton
Asst Chief Jack Austin Jr.
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Choctaw Nation
Notice!!! If you do not fill out the form to the best of your knowledge you may not receive your medications. Please be sure to include a valid phone number or email so we can contact you incase more information is needed.
Personal Information
First Name
*
Last Name
*
Date of Birth
*
Chart Number
Email
Phone Number
*
Secondary Number
Primary Physician
Clinic
Atoka - Atoka Clinic
Durant - Durant Health Clinic
Idabel - Idabel Clinic
Hugo - Harry Belvin Clinic
McAlester - Calvin C. Beams Clinic
Poteau - Rubin White Refill Center
Stigler - Stigler Clinic
Talihina - CNHCC Hospital
Medication Information
Please enter your medication(s) clicking the add meds button to add more.
Medication 1
Perscription Number
OR
Name of Medication
Dosage
Frequency of Usage
Medication 2
Perscription Number
OR
Name of Medication
Dosage
Frequency of Usage
Medication 3
Perscription Number
OR
Name of Medication
Dosage
Frequency of Usage
Medication 4
Perscription Number
OR
Name of Medication
Dosage
Frequency of Usage
Medication 5
Perscription Number
OR
Name of Medication
Dosage
Frequency of Usage
Medication 6
Perscription Number
OR
Name of Medication
Dosage
Frequency of Usage
Medication 7
Perscription Number
OR
Name of Medication
Dosage
Frequency of Usage