St. Charles - McAuley Free Health Clinic

Physical Address: 4915 N. State Street
Mailing Address:  5024 N. Grove
Oklahoma City, OK  73122
405-495-4667

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Fields with a * are required.

Prefix: Last Name: *      First Name: *  
Address:    
City:                State:     Zip Code: 

Home Phone:*   Work:    Other: 

Types of service you would like to offer:
 

Amount of time you would be able to commit to the clinic per month: 

Experience or related skills:
  

Clerical: Receptionist   Medical records
Medical: Laboratory Technician Nurse
  Pharmacist Phlebotomist
  Physician Other

List any licenses you currently hold:
 

If applicable, Malpractice Insurance Company and Policy:

Spanish or other Foreign Languages (specify which ones):

Other information or skills:



You may also download this form in Adobe Acrobat, and Mail it to the Clinic at:
St. Charles Clinic
5024 N. Grove
Oklahoma City, OK  73122
 

Patient Relations:

1. All volunteers are expected to treat every patient with respect.
2. All patients will be attended on a first come, first serve basis with the exception, obvious emergencies
3. Confidentiality must be respected regarding all patients.  Volunteers must not discuss patient cases outside the clinic.