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7 Porat BUREAU OF investi@xt0N MEDICAL TREATMENT/REFUSAL FORM. pate 9/1/03 IF PRISONER REQUIRES OR REFUSES MEDICAL TREATMENT, ARRESTING OFFICIAL WILL COMPLETE THIS FORM PRIOR TO COMMITTING TO ANY CORRECTIONAL FACILITY NAME: 2 TOT ~ CHARGES j . NARRATIVE: Compicder {psirsion He <1 TITLE:__(F use:_{030 b7C -1 NARRATIVE: TITLE:_{& usc: 4049 DATE OF OFFENSE: DATE OF ARREST: 9/1/02 \ PLACE OF ARREST: Nw) ort, uy ( ARRESTING OFFICIAL(NAME) NATURE OF ILLNESS/INJURY: (OLD IN. ( NEW INI. tootn_infecHon If TREATED BY E.M.S. OR HOSPITAL FILL OUT THE FOLLOWING TREATED BY DR/E.M.S. HOSPITAL: ADMITTED ( )YES ( UNO DIAGNOSIS: MEDICATION PRESCRIBED : Ove Cowie YES (JNO IF PRISONER REFUSES MEDICAL TREATMENT FILL OUT THE FOLLOWING DATE: TIME: PRISONER’S SIGNATURE: REMARKS: (PRINT) . hQS resorption he ciopped OF bday © Duane Reade FBI(19-cv-1495)-2091