Pokagon Health Services
Recording:
Audio Player
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authorized by [the one who allows things]
Recording:
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witness [the one who watched]
Recording:
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signature of PHS staff [signature of worker]
Recording:
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address [where do you live at?]
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Tribal affiliation [where are you enrolled at?]
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employment [where do you work at?]
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employer [where do you work at?]
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date [what is it today?]
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patient name [what are you called?]
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relationship to patient [how are you related to h/s?]
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Date of birth [when were you born?]
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h/s parent(s)
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are you a veteran?
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phone number [write your phone number]
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emergency contact [who should be called?]
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patient [who will be seen?]
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signature of patient [make your mark]
Recording:
Audio Player