INMATE MEDICATION INFORMATION FORM
INMATE INFORMATION
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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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