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Parkland Health & Hospital System Patient Name:'
Dallas County Jail Health
Dallas, Texas Book-in Numbei
Date of Birth:
SICK CALL REQUEST Race:
(KITE)
blem: ("Please write legibly)(All health care requests are subjactbajiw.
Pleas? Do Not Write Be low This Line or On the Back ofThis Form
\ Received Date f\ iMc:„,__________.__,___
Zj O Emergent O Urgent
^ DDcntal DMedicai •Mental Health •Medication OOBGY
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\S> 1 riaged by: Signature/1 itie Credentials ot Healthcare Professional
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Printed Name of l-lei
O Scanned • Nurse Guideline done D Nurse Note done O MHL Note done O Releasl
Signature/Title/Credentials of Healthcare Professional Printed Name of Healthcare Professional
03/2013 .