Jail Medical Receipt
Record the receipt of medical services or items for a person in custody.
Inmate and Encounter Details
Inmate Full Name
*
First Name
Middle Name
Last Name
Booking Number / Facility Inmate Identifier
*
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Housing Unit / Cell Block
Please Select
Unit A
Unit B
Unit C
General Population
Administrative Segregation
Other
Date and Time of Medical Receipt
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Issuing Medical Staff Member / Officer Name
*
Medical Receipt Details
Receipt Type
*
Medication
Treatment
Medical Supply
Clinic Visit
Other
Item or Service Description
*
Quantity or Dosage
Reason for Receipt or Medical Need
Date and Time Administered or Issued
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Authorization and Acknowledgment
Acknowledgment
*
I acknowledge that I received the listed medical item/service and that this receipt is accurate.
Signature
*
Submit Receipt
Submit Receipt
Should be Empty: