Case 2:85-cv-04544-DMG-AGR Document 420-4 Filed 04/23/18 Page 78 of 81 Page ID #:16721 Shiloh Treatment Center, Inc. Admission Packet Office of Refugee Resettlement Medication Information and Reconciliation Include all medication the client is currently prescribed. Date of Completion · Source of Medication Information: Check All That Apply ~~armacy Label Form Completed By 0Physician Prescription 0Parent or Client ~ischarge Summary/Records From Transferring Facility OOther: Facility: - - - - - - - --------------------------For Use by Clinic Staff Medication at Admission Name of Medication Dose Frequency Route l.n i1 I rf1 rn {t.,Q_; Prescriber P6 J/JD//14 le)\ vJ V l -e\1Ph r-0 t1rotQ'('(1 IDDOmar ri,o Di Wl l om Q,'£ (R CfJ'J~ 6H) 15ord. 0~0 Oxc6r\-\,yz.e..olri Q.., \ S,.rhru l Q,~ 0 60m~ do.:l1, Date Prescribed Target Symptoms Last Dose Discontinue Order on Change Quantity Quantity on Admit on Admit Provided at Received at Admit Admit Admit Date nme \/ I l\al a!Do~ i-1°t-n So. 01; '{'{) 9;,...,-:; A-Wl P6 \J ·~ \\o_ltyooS s-ic,-11 ~ '?,(.Lfe., %i iW1