U.S. Air Force - 59th Medical Wing Forms

This form is used for daily and monthly checks of code carts. It helps ensure that code carts are properly stocked and in working condition.

This form is used for recording the inspection of a life support code cart.

This form is used for recording a patient's departure from a medical facility against the advice of their healthcare provider. It serves as a release from responsibility for the facility.

This form is used for reporting the monthly hours worked in off-duty employment.

This form is used for keeping track of off-duty employment for officers and civilian equivalents in the 59th Medical Wing. It ensures that all necessary steps are taken and documentation is completed for this type of employment.

This form is used for recording and monitoring the temperature of refrigerators and freezers.

This Form is used for civilian employers to certify the employment and earnings of a military member for purposes such as obtaining a loan or applying for benefits.

This form is used for disclosing and obtaining consent for anesthesia and/or perioperative pain management during a medical procedure.

This form is used for disclosure and consent for medical and surgical procedures.

This document is used for verifying medical procedures or non-procedures in medical records.

This form is used for documenting the verification of procedures in medical records at the 59th Medical Wing.

This Form is used for documenting the use of procedural sedation during medical procedures. It helps track the medications and vital signs during the sedation process.

This Form is used for requesting volunteer services at 59th Medical Wing.

This Form is used for providing volunteer information to the 59th Medical Wing.

This Form is used for obtaining authorization and providing treatment statements by the 59th Medical Wing.

This Form is used for requesting an amendment or correction to your medical record at the 59th Medical Wing (MDW).

This form is used for acknowledging the receipt of the Military Health System Notice of Privacy Practices. It is important for individuals to understand their rights and how their health information will be protected within the military healthcare system.

This Form is used for the Custodian of Medical Records at the 59th Medical Wing to provide an Affidavit.

This form is used for recording the volunteer hours at the Wilford Hall Ambulatory Surgical Center.

This Form is used for determining sobriety in the context of the 59th Medical Wing (MDW). It helps evaluate an individual's ability to operate a vehicle or perform duties that require sobriety.

This form is used for reporting and tracking cases of MRSA, Group B Strep B, and VRE in the 59th Medical Wing.

This form is used for documenting urine test results and related information. It is often used in medical settings for tracking patients' health conditions.

This document is used for recording and tracking blood culture samples in the medical field.

This Form is used for anesthesia preoperative evaluation.

This Form is used for recording respiratory information and data.

This form is used for requesting standard lab tests at the 59th Medical Wing.

This Form is used for documenting and tracking aerobic (superficial) wound healing progress within the 59th Medical Wing.

This form is used for recording and analyzing stool samples in medical settings. It helps healthcare professionals track and evaluate digestive health.

This Form is used for conducting a screening questionnaire during a 2-5 year visit at the 59 MDW medical facility.

This document is used for conducting a screening questionnaire during the 12-23 month well visit at the 59th Medical Wing.

This Form is used for screening questionnaires during a 6-11 year visit at the 59th Medical Wing.