INFORMATION SHEET
Physician's
Name: ____________________Licence #: _____________________
Clinic Name: ________________________________________________________
Address: _________________________ Tel#: ____________________________
City: ___________________ Postal Code: _______________
Fax#: _________ |
SUSPECT
Suspect Name: ___________________________________
DOB: ____________
Address: _________________________Tel#: ______________________________
Can you identify this person? YES [ ] No [ ]
Can you comment on;
HEIGHT: ___________ WEIGHT: __________ HAIR: __________
EYES: ______
Do you have any means of recalling the visit(s) with the person?
YES [ ] NO[ ] |
THE FOLLOWING INFORMATION
REPRESENTS KNOWN INTERACTION BETWEEN YOU AND THE SUSPECT. PLEASE
CONFIRM THE ACCURACY OF THE NOTED ENTRIES BY MARKING YOUR CHOICE IN
"CONF" CONFIRM
|
PRESCRIPTIONS
SOUGHT AND OR GIVEN
|
CONF
|
DID PERSON
ADVISE YOU OF ANY PRESCRIPTIONS OF NARCOTICS OR CONTROLLED DRUGS
THAT WAS SOUGHT IN THE LAST THIRTY DAYS FROM OTHER DOCTORS?
|
| DATE |
TYPE
& STRENGTH |
QUANT. |
Y |
N |
YES |
NO |
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PRACTITIONER'S SIGNITURE:
______________________________________
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