6202 East 61st
Tulsa, OK 74136

Tel: (918) 494-8830
Fax: (918) 494-8837

Home

Services

Admissions

Contacts

6202 East 61st
Tulsa, OK 74136
Tel: (918) 494-8830
Fax: (918) 494-8837

Home | Services | Admissions | Contacts

We would appreciate it if you would take a few moments to answer the following questions. Please be assured that we do not share or sell personal information about you except when we have your permission.

Patient Name:

Age:

Date of Birth:

Social Security Number:

Hospital Admissions Date:

Discharge Date:

Current Diagnosis:

Name of Inquirer:

Bold = Required field

Gender:

Patient Currently At:

Home

Hospital

Other

Will Physician Continue Care in the Facility:

Yes

Please Choose Level of Care:

Private Pay

VA Contract

Medicare

Insurance

Medicaid

Respite

Check the Following that Applies:

Mentally Alert

Forgetful

Disoriented

Confused

Mental Illness

Wanders

Tube Feeding

Ambulatory

Walks w/ Assist.

Chair Ridden

Bed Ridden

Smokes

Non-Smoker

Paralyzed

Requires Bedrails

Special Mattress

P.T/O.T/S.T.

Wounds

Obesity

Oxygen

Continent

Incontinent (Briefs)

Ostomy

Catheter

Feeds Self

Assist w/ Meals

Relationship to Patient:

Phone:

Admissions

The mission at MapleWood Care Center is to make the transition as easy as possible focus is to provide the patient with the best care.

We welcome you to come and tour our facility and just see what we have to offer. If you are interested in choosing MapleWood Care Center for long term care or short term care . Please click on the box below to download our pre-admission form.

lnk