Form OP-140701A "Consent for Medical, Dental and Mental Health Treatment" - Oklahoma

What Is Form OP-140701A?

This is a legal form that was released by the Oklahoma Department of Corrections - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2020;
  • The latest edition provided by the Oklahoma Department of Corrections;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form OP-140701A by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Corrections.

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Download Form OP-140701A "Consent for Medical, Dental and Mental Health Treatment" - Oklahoma

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OKLAHOMA DEPARTMENT OF CORRECTIONS
CONSENT FOR MEDICAL, DENTAL AND MENTAL HEALTH TREATMENT
Facility: ___________________________ Date: ______________Time: ___________
I hereby authorize __________________________________ and assistants to perform
(Name of Provider)
the following operation, procedure or treatment:
The nature and the extent of the intended operation, procedure or treatment have been
explained to me in detail.
I have been advised by the above provider of the following alternatives, if any, probable
consequences if I remain untreated, risks and possible complications of proposed
treatment as indicated:
I acknowledge that no guarantee or assurance has been made as to the desired result
that may be obtained.
If any unforeseen condition arises in the course of the operation, procedure or treatment
calling for the judgement of the provider for procedures in addition to or different from
those now contemplated, I further request and authorize the provider to do whatever is
deemed necessary.
I consent to the administration of anesthesia to be applied by or under the direction of
the above named practitioner or his designee, and the use of anesthetics, as he/she
may deem advisable.
Please check one of the boxes below, which describes your situation:
I have read and fully understand the terms of this consent and acknowledge that
the explanations referred to were made and that all blanks have been filled.
OR
I do not speak or read English and an interpreter has explained this consent to
me.
I fully understand the terms of this consent and acknowledge that the
explanations referred to were made and all blanks have been filled.
Name of Interpreter: ____________________________________
Inmate Signature: ________________________________________ Date: __________
Health Care Provider: _____________________________________ Date: __________
______________________________________________________
____________________
Inmate Name (Last, First)
DOC Number
DOC 140701A (R 12/20)
OKLAHOMA DEPARTMENT OF CORRECTIONS
CONSENT FOR MEDICAL, DENTAL AND MENTAL HEALTH TREATMENT
Facility: ___________________________ Date: ______________Time: ___________
I hereby authorize __________________________________ and assistants to perform
(Name of Provider)
the following operation, procedure or treatment:
The nature and the extent of the intended operation, procedure or treatment have been
explained to me in detail.
I have been advised by the above provider of the following alternatives, if any, probable
consequences if I remain untreated, risks and possible complications of proposed
treatment as indicated:
I acknowledge that no guarantee or assurance has been made as to the desired result
that may be obtained.
If any unforeseen condition arises in the course of the operation, procedure or treatment
calling for the judgement of the provider for procedures in addition to or different from
those now contemplated, I further request and authorize the provider to do whatever is
deemed necessary.
I consent to the administration of anesthesia to be applied by or under the direction of
the above named practitioner or his designee, and the use of anesthetics, as he/she
may deem advisable.
Please check one of the boxes below, which describes your situation:
I have read and fully understand the terms of this consent and acknowledge that
the explanations referred to were made and that all blanks have been filled.
OR
I do not speak or read English and an interpreter has explained this consent to
me.
I fully understand the terms of this consent and acknowledge that the
explanations referred to were made and all blanks have been filled.
Name of Interpreter: ____________________________________
Inmate Signature: ________________________________________ Date: __________
Health Care Provider: _____________________________________ Date: __________
______________________________________________________
____________________
Inmate Name (Last, First)
DOC Number
DOC 140701A (R 12/20)