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Date of Service
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Agency_____Police Department
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Name
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Case #
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Date of Birth
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Age
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Charge(s)
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Select All That Apply
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Section I: Evidence Collection Blood Alcohol/Drug Withdrawal
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Section II: Pre-Booking Examination Medical Clearance “Okay to Book”
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Section III: Post-Booking Treatment
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Date of Arrest
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Booking Number
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Requesting Officer(s)
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ID #
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Comments
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