BEST RECOVERY HEALT CARE, INC . 1708 N. Laurent 5t, Victoria. Texas 77901 Phone: seam-9122 Fax1361-572-8607 James Hebert Natalie Carro?. MD. Executive Dlrectorngogsor Medical Director MEDICATI ON RECORDS Medication taken to VP '3 ?Inf-imam n) ONE (1) OF TO BE ADMINISTERED DAILY. Number of doses/bottles delivered: NOTE: Each bottle contains Mme of METHADONE Hydrochloride. Methadone hydrochloride is a scheduled ll controlled substance Controlled WW and security measures are required. Date Name :Time Date Signature of physician or nurse 9mm 90121;, ?0900 911141]? rmym?ltnl Zen/Z a) Izolra tbh?uylm {Urn}- 701?; .150 9/94/17 Him/rm; (mm/c. 0409 49th 6119+ om co 9cm ngm??ty? vomj 0900 ?2va Klimt -330m3 0900 A Total Doses/ Bottles 9 41121;? ?lm/ml pail/l6}? LUU 08V Date Dellvered Received By Medication should be administered on the dates indicated above. Medication not administered in accordance with the above schedule must be returned to Best Recovery Health Care. inc, Attn: Nurse (361) 572-9122. Revised: December 2016 73am. James Hebert Executive DirectcrISmsor mate BEST RECOVERY HEALTH CARE, INC. 1703 N. Laurent St. Victoria. Texas 77901 Phone: 36-572-9122 Fax: 361-572-8607 Natalie Carroll. MD. MEDICATION RECORDS Medication taken MEDICATION TO BE DAILY. Number of doses/bottles delivered: Each bottle containngs of METHADONE Hydrochloride. Substance Act Appropriate accountability and security measures are required. mun/hr. Mm Liz/a gateg Delivered By? Medication should be administered on the dates indicated above. Medication not administered? In accordance with the above schedule must be returned to Best Recove Health 0 Attn: Nurse (361) 572-9122 are. Revised: December 2016 Date Name Time Date Signature of physician or nurse $111219ij (ilmt JD 2 49.01:: 0900 Total Doses] Bottles Cf Magi aim) Redeived By - .57 PM INDIVIDUAL . If . . NARCDTIC RECORD {1er Cum Otdared Tim Dose Oral or Either Adm. By Nurse - Signature I to Shel Bag. Retain for Recmds. 4 M. m. 6 of Discontinuance Amount Remaining of Dispns?lcn Signature 1?2014 CONTROLLED SUBSTANCE PERPETUAL INVENTORY IIJSAGE RECORD inmate Name Floorstock: Alamo Physician: ?ag! 'Qg rm CHM Date Received /Transferred: Amount Received Transferred: Received/ Tran?fgredfrom: 'Received by: Witnessed by: 1 A I All spaces must Fadgnd??d for each dose given. All records must be legible and accurately completed. Medication: Strength: I Two persons must witness receipt, transfer, waste or destruction of controlled ?1 1? GD substances. Directions: Must be com leted if waste occurs 0R AFFIX LABEL FROM CARD lN THIS SECTION Patient . Dose Doses Administered By Waste Witness Date Time Last Name, First Name Prowder On Hand Given Wasted Balance signature Signature II Jamm?ilm Clmi 'l l0? ?5 Cl (?mar gm; 4: mug all}: 3?67, 4. ,5 ?c??q?ogb LUIS 9i {Liarrina?inloll Medication removed from count in the following manner: (circle one) Quantity destroyed sent out returned: Destroyed Sent out for destruction Personal Property Returned to Inmate Date: Time: Nurse veri?cation: Witness veri?cation: Pharmacist signature: (required for destruction): Medication transferred to another book or page: (update index page) Book: Page: Quantity transferred: Date: Time: Nurse veri?cation: Witness veri?cation: AA CONTROLLED SUBSTANCE PERPETUAL INVENTORY USAGE RECORD inmate Name Floorstock: 613" I ?31-510 a! frl' ID RX 3? Physician: 6w 2 i?i?v Medicationzl l: j: 1 9411439. Strength: Directions: i amb?fr on AFFIX LABEL BUSTERERD IN THIS SECTION Date Received /Tiansferred: Al I pas/18 Amount Received Transferred: Received Transfeged from: Received by: Witnessed by: ?fd/U All spaces must be completed for each dose given. All records must be legible and accurately completed. Two persons must witness receipt, transfer, waste or destruction of controlled substances. . Must be completed if waste occurs. 3:0 We ?me Last Name Elite Wider 33:: @2353; Balm ?2:23:55: By ?1me 8? ~19 30 me. Lei/i 90 9* 3 ?7 (Y P2.) also [00 mi "t 4 (PQp'a? 3:8le .57) m; 5 504:4 I - (Emil 7,75 Lfo mi la #on'r?l hwy?; - ?30 mi. BO ~44mZ? 1,0,1? Medication removed from count in the following manner: (circle one) Quantity destroyed sent out returned: Destroyed Sent out for destruction Personal Property Returned to Inmate Date: Time: Nurse veri?cation: Witness veri?cation: Pharmacist signature: (required for destruction): Medication transferred to another book or page: (update index page) Book: Page: Quantity transferred: Date: Time: Nurse veri?cation: Witness veri?cation: v- 45 . ?Ma 09-10-318 15:32 FROM- Gulf Band Center 381?578?5500 T-309 F-982 NAMEDdrGULF BEND CENTER WW 2 6502 Nani?:7 TX mm (351) svs-osu :33. Janus Dalt'aqM?. 3.1-2 DEM: BD653514B - -'rx Lid: mm a; 26 1?1! Lied} 36403 DPSI: 50113144 - . punish; MD. ?A?h . glam . UAW 1308:" - . I 8 I ilk?L ?81145. ?pb 996% ?Ramls 1 4' Nolic?u: APO 09m 3. .. Re?lls 1 2 3 4 NoRu?Ds .4- Re?lls 1 z- 3 4' 1?1th 5. .- Re?lls? 1 2 3 4 'NoRe?lls . . if . . - Musician?s Sjgnattn'e: - 'm - UNIVERSITY OF TEXAS MEDICAL BRANCH Comprehensive Health Solutions SICK CALL REQUEST PART A: To be completed by inmate) Date: 8 ?1 6 Name: [71+ '1 County 9181.63 Service needed: medical til Dental [1 Mental Health {it Other Reason for Health 1: [?18 1?0 Dr. or Sow-?cont about wtihirm Me?H?Imlonr c: lil?Hf scl? +im< (?Ur-wt. bx? UtthJox W?l'mer?rl? plant mn?y?dmftaadmmx% How long have you had this problem? Hours: Days: 2 PART B: (To be completed by medical personnel- Do not write below this line) . .Medical Reply: (Mire/My Medical Staff Member's Signature ?meme- ?ag-tor"? . ?Human-NW" -. .- ,?wrvewwzm - - 3i-?-ir- .- I (?ryvy?vv-W- ?J'pn' . - ., OF TEXAS icoa?gv? Comprehensive Health Solutions SICK CALL REQUEST . 2049/ PART A: (To be completed by Inmate) Date: 31 ?at I 3 Name: It.? County (0 l8 3- Q) . Serviceqne?edeEEJ?/ledlcal? '0 Rental- Mental l-lealth Either Reason for Health Services Appointment: Mantl? +0 F301 est? meat How long have you had this problem? Hours: :1 PART B: (To be completed by medlcal personnel- Do not write below this line) Medical Reply: 4/ 9 ad 75/ Date Medical Staff Member?s Signature 720' 3. ?a UNIVERSITY OF TEXAS MEDICAL BRANCH 3 Comprehensive Health Solutions 3 f; 5; 5Q SICK CALL REQUEST SEP 2 28?] PART A: be completed byi mate) Date: ll] Name: Harris}, County #2 6 (133320 Service needed: Wedlcal 13 Dental {3 Mental Health Other Reason for Health Services Appointment: (R WK 841/ PGHA 3 6 lag Ljey .1 3 1 3 How long have you had this problem? Hours: ?3 Days: PART B: (To be completed by medical personnel- Do not write below this line) ?i 1 44240 ii MM- ml 20 lg 25?? Medical eta? Me?r?nber's Signature hate 1 220 i UNIVERSITY OF TEXAS MEDICAL BRANCH Comprehensive Health Solutions it if: 3 VE SICK CALL REQUEST SEP 2 8 20,8 PART A: (To be completed by inmate) Date: 0V 7?3 ?a Name: C(il?d? (N Aj?a? County Service needed: Medical El Dental Ct Mental Health El Other . . Reason for Health Services Appointment: SWAP :1 Pam :1 How long have you had this problem? Hours: Days: 4'4 PART B: (To be completed by medical personnel- Do not write below this line) Medical Reply: (3111 41% ?e . @447?, 07/29 ml :2 9 It? Medical ?S'taff Member?s?Signature 'Date 1? UNIVERSITY OF TEXAS MEDICAL BRANCH Comprehensive Health Solutions SICK CALL REQUEST PART A: (To be completed by Inmate) Date: (Vita/1% (A - Name: County GLIGQE dab\ . Service needed. medical a Dental :3 Mental Health Other 7 Reason for Health Services Appolntment: 6341* Sk?bu exl?m Pam ?Mitch, INICAOWQ 0V5 Mod: Mm px?m llama)? emulate ?vwm Mlle-4s was 3:51ng T?kcem ktIpMs. CM mass. How long have you had this problem? Hours: Days: 5 PART B: (To be completed by medical personnel- Do not write below line) Medical Reply: 01/35le Medlcal Staff Member's Sldnature Date UNIVERSITY OF TEXAS MEDICAL BRANCH Comprehensive Health Solutions SICK CALL REQUEST PART A: (To be completed by inmate) Date: l0! 1? ?3 Name: 5 on County H616 9 90\ i . I Service needed: medical Ci Dental El Mental Health Other Reason for Health Services Appointment: WM kanAAicLs How long have you had this problem? Hours: Days: PART B: (To be completed by medical personnel? Do not write below this line) Medical Reply: Medical Staff Member?s Eignature Date UNIVERSITY OF TEXAS MEDICAL BRANCH 0/ - .. Comprehensive Health Solutions .. SICK CALL REQUEST 3 {3 PART A: (To be completed by inmate) Date: Lb 0?3 Cb 001 0 420 Name: 1 ?lb/ti H71 Fl 0 Q?Ton County ?1 Service needed: wedicai El Den ai El Mental Health Other Reason for Health Services Appointment: Kev elm mW?e, ITEQQ Carma Mb mime mowvollilahAlWoS/d?Aeigvow How long have you had this problem? Hours: ?Days: PART B: (To be completed by medical personnel-Do not write below this line) Medical ReplylO/O?/Igooao Medical Staff Member'd Signature Date \m UNIVERSITY OF TEXAS BRANCH 220 Comprehensive Health Solutions I SICK CALL REQUEST ?u ?ll ?1 PARTA: (To be completed nmate) Date; lg 1? EMS Name: Lll??l' County #qul? OCT 0 Service needed: QKrledlcal Dental Mental Health [1 Other Reason forHealth ServicesAppointment: kahuna} 09-? BB Jamef fake 00le ml Mu mm Mala Puma? a . AH new, F73 How long have you had this problem? Hours: Days: PART B: (To be completed by medical personnel- Do not write below this line) Medical Reply: Wu; 0027 Medical Staff hembers Slg?ature Date