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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
g_
\S> 1 riaged by: Signature/1 itie Credentials ot Healthcare Professional
                                                                                           ^
                                                                              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   .
