INMATE MEDICATION INFORMATION FORM
INMATE INFORMATION
PRINT SUBMIT FORM
If you believe your family member is suicidal or has an urgent medical condition that requires immediate attention, call
the jail immediately at (805) 781-4600 and ask for the on-duty sergeant.
FULL LEGAL NAME OF INMATE: ____________________________________________________________________________________________________
STREET ADDRESS: ____________________________________________CITY: ___________________ STATE: _____ ZIP CODE: ____________________
DOB: _____________________________ BOOKING #:___________________________________________________________________________________
FAMILY CONTACT INFORMATION
FAMILY CONTACT NAME: ________________________________________________________________ RELATIONSHIP ___________________________
STREET ADDRESS: ____________________________________________CITY: ___________________ STATE: _____ ZIP CODE: ____________________
DAYTIME PHONE: ________________________________________________ EVENING PHONE: _______________________________________________
Forms that do not contain your contact information may not be considered valid.
PSYCHIATRIST/TREATMENT FACILITY INFORMATION
PSYCHIATRIST: __________________________________________________________________ DATE LAST TREATED: ___________________________
LAST TREATMENT FACILITY: ______________________________________________________________________________________________________
STREET ADDRESS: ____________________________________________CITY: ___________________ STATE: _____ ZIP CODE: ____________________
PHONE: _________________________________________________________ FAX: __________________________________________________________
MEDICAL INFORMATION
DIAGNOSIS: ____________________________________________________________________________________________________________________
DAYTIME MEDICATIONS: _________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
DOSAGE: ______________________________________________________________________________________________________________________
NIGHTTIME MEDICATIONS: _______________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
DOSAGE: ______________________________________________________________________________________________________________________
PRIOR ADVERSE MEDICATION EFFECTS (i.e. side effects, allergies, poor efficacy): __________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
IS SUICIDE A CONCERN? NO ______YES ______ IF YES, WHY? ________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
IF YES, IMMEDIATELY CALL (805) 781-4600 AND ASK FOR THE ON –DUTY SERGEANT
_______________________________________________________________________________________________________________________________
OTHER MEDICAL CONCERNS: _____________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
MEDICATIONS PRESCRIBED FOR THESE CONDITIONS: _______________________________________________________________________________
MEDICAL DOCTOR’S NAME: _______________________________________________________ OFFICE PHONE: _________________________________
STREET ADDRESS: ____________________________________________CITY: ___________________ STATE: _____ ZIP CODE: ____________________
JAIL MEDICAL/MENTAL HEALTH SERVICES
FAX: (805) 781-5342 or Email: sh-inmate-medical-pdf@co.slo.ca.us
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