Variety Care Teen Clinic Form

Your Name* This field is required.

First Name

Middle Initial or Name (optional)

Last Name

Preferred Name and Pronouns

Preferred Name (optional)

Preferred Pronouns (optional)

Birthdate* This field is required.Please enter as MM-DD-YYYY or use the date picker option.

Date

Teen Clinic serves patients between the age of 13 and 21, but Variety Care is still here for you!

Please call us at (405) 632-6688 for more information on services for patients age 22 and up.

If you entered your age incorrectly, tap "Previous" and correct your entry.
If you are 22 and up, there's no need to fill out this form. You may close this window.

Do you want access to birth control through Teen Clinic?* This field is required.Select YES if you want to have access to birth control now or in the future through Teen Clinic. (NOTE: Education programs, pregnancy tests, STI treatment & testing, and emergency contraception are available even if you select no.)

YESNO

Do you want access to STI Testing through Teen Clinic* This field is required.Select YES if you want to have access to STI Testing now or in the future through Teen Clinic. (NOTE: Education programs, pregnancy tests, and emergency contraception are available even if you select no.)

YESNO

I am under 18, but I give Variety Care consent to provide me medical care because:* This field is required.(select all that apply) ◆ = under 63 O.S. §2602 ◇ = under 42 U.S.C. 1905(a)(i), (a)(4)(C)

I am married ◆

I am or have been pregnant ◆

I have/had a STI ◆

I am legally emancipated ◆

I have a child ◆

I have/had a drug or alcohol abuse issue ◆

I am independent from my parents/guardian and support myself ◆

I have Medicaid and I consent for family planning services ◇

I will be bringing a parent/guardian with me

I will call my parent for verbal permission at the appointment

I am 18 or older

None of these apply to me

I am under 18, but I give Variety Care consent to provide me medical care for the following reason:* This field is required.(select all that apply) ◆ = under 63 O.S. 1-532.1 ◇ = under 63 OS 2602)

I am consenting to only STI Testing ◆

I am under 18; if a test confirms I have an STI:* This field is required.(select all that apply) ◇ = under 63 OS 2602)

I give consent for treatment and prevention ◇

I give no further consent

Since you do not qualify for minor self-consent, you will need parental permission to access birth control services at Teen Clinic. If that is not an option for you, please text our hotline at 405-882-3598.

Consent for Services* This field is required.This is a consent form. Please read carefully and ask a staff member if you have questions

I approve medical care from Variety Care providers and staff. I understand there are dangers and risks from any medical treatment. I accept these risks.

I understand that I am responsible for all the charges, whether my insurance pays all of it or not.

I understand that lab tests are separate from my visit and I may be charged an additional fee for them.

I understand that this consent is valid for up to a year. I may stop my consent earlier by telling Variety Care Staff that I no longer consent.

I may only consent to the services allowed under 63 O.S. §2602 and Variety Care might have limits on what they can treat without consent from my parent/guardian. My provider will discuss this with me if necessary.

Your Gender* This field is required.

Are you currently enrolled as a student?* This field is required.

YESNO

How may Teen Clinic contact you?Please provide at least one way for your Teen Clinic provider to contact you with personal health information.

Main phone number for health-related calls

Alternate phone number for health-related calls (optional)

Home Address* This field is required.IMPORTANT: An address is required to set up your account, but you will NOT receive bills or communications from Teen Clinic at this address. If we need to contact you with personal health information, Teen Clinic will use the contact information you provided on the previous screen to reach you directly.

Street Address

(optional) Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Do you receive SoonerCare?* This field is required.(SoonerCare is the State of Oklahoma's Medicaid program.)

YESNO

If you do NOT currently receive SoonerCare, would you like help applying?* This field is required.(SoonerCare is the State of Oklahoma's Medicaid program.)

YESNO

Please select your preferred pharmacy* This field is required.NOTE: Britton offers a drive-up pharmacy window option.

Britton Health Center (721 W Britton Road)

Straka Terrace (1025 Straka Terrace)

Lafayette (500 SW 44th Street)

North Portland (5320 N Portland Avenue)

Sliding Fee Scale

I want no eligible discount. I decline to apply for the sliding fee scale program.

Almost done - last questions!* This field is required.

How did you hear about Teen Clinic? (select all that apply)

What language do you prefer?

What is your Race?

What is your ethnicity?

I agree that all the information I have given is correct.* This field is required.Acepto que toda la información que he proporcionado es correcta.

Clear

Variety Care Teen Clinic Form