"

.f, ' Sl~ter County Detention C~,ter

Date
06/06/2012
CRIMINAL ARREST DATA Booking Number
2012-001220
NAME Last First Mi Alias
VALDEZ, GILBERT
ADDRESS (City, State, Zip Code) Phone No, Race Sex
4918 DEAN ST FT MYERS FL 33142 (239) 240-1425 W M
D.O.B, 1 AGE P.O.B. HEIGHT WEIGHT HAIR EYES BUILD
09/14/1'968 43 FLORIDA 5'09" 250 BLK
ARREST NUMBER S,S. NUMBER ., TIME BOOKED TIME PROCESSED
265-73-9906 11:42:00 13:16:00
OCCUPATION EMPLOYER SCARSrrATIOOS
LABORER MULTI TATS

.
NEXT OF KIN & RELATIONSHIP
•
(Mother,Father,Wife,Husband,etc,) ADDRESS PHONE NO. RELIGION

CATHOLIC
MEDICAL PROBELMS/INFECTIOUS DISEASES ATIORNEY (If Known) MARITAL STATUS

NATT Single
ARREST (Date & Time) ARRESTING OFFICER ARRESTING AGENCY BOOKING OFFICER RECEIVING OFFICER

RODRIGUEZ K. SLANKER

TIME OF WEAPONS/DRUGS BOND DATE ADDED & AGENCY

STATUTE # OFFENSE ARREST OR ALCOHOLINVOL VED

06/06/2012
COMMIT OIC Dwisl 130 Days 11:42:2 NN Scso
OBTS # OFFENSE TYPE CASE/ACTIVITY # WARRANT/CAPIAS/CITATION' ARRESTINGOFFICER
600102 Misdemeanor Remanded From Cou

OBTS # OFFENSE TYPE CASE/ACTIVITY # WARRANT/CAPIAS/CITATION' ARRESTINGOFFICER

I

OBTS # OFFENSE TYPE CASE/ACTIVITY # WARRANT/CAPIAS/CITATION' ARRESTINGOFFICER

,\
'j OBTS #. OFFENSE TYPE CASE/ACTIVITY # WARRANT/CAPIAS/CITATION' ARRESTINGOFFICER
f

OBTS # OFFENSE TYPE CASE/ACTIVITY # WARRANT/CAPIAS/CITATION' ARRESTINGOFFICER

I

Inmate Guide Book # Orientation Conducted: Y TELEPHONE USED: STATUS NURSE NOTIFIED
YES' Inmate Signalure: Number: o
Threat / Violent Escape Risk Suicide Risk
o
o o 0
Medical Alert

o Number:
Number: o
PHOTOGRAPH

HOLD INFORMATION Right Thumb/Admission Righi Thumb/Release

bin 32

RELEASE INFORMATION

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Patient Name;
mcMAS E. CENTER
LJNGLi:."'7 MEDIOL

OOB: C\-lY_-_~_~ _ 1425 S US Hwy301 .g""'b.rv:i.11a,

(352)793-5900 • Fax (352)793-95S8
n 335<35

SlJMr:Elt CCmm;a DETENTION CZNTER

ALLERGIES: NI[ft--
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1:o!1EDICATION.RECORD
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 DOB: maMAs E. LANGLEY,'rfEDIC4L CENTER
U25 So US Hwy 30' • Sumterville, FL 335.15
(352) i93-5900. FlU (352) 793-9558
SUMTER COUNTY DETENTION CENTER

Today's date: '8 ~2 1 ':'/a. ADULT ACUTE CARE

Drug Allergies:_A_)k~B~ _
Risto ry 0 Scheduled VISit 0 Unscheduled 0 U~t
Review ofS}'3te= (Nel:=aIy for DdailedlComp EvaJ)
W~bC r..o.. Y !'l Vlsloo a.olr' Y Ii N.u.e"'Y~.'.!1Wi>g, Y N
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Rnb Y N Sio"" Problems Y N DiarrhealConstip Y N
Dl:aioess Y N Son: Throat Y Ii Abdominal Pain. Y N
Ht:Ildscbe Y N OIac Paia Y Ii IGdaey Disease Y N
Mood ClIaogtS Y N Leg SwelUog Y Ii Painful Urination Y N
Wt:IlkJlfUllda Y ..N SbortofB •.••.lI1 Y N Joiatl'aia Y N
Namba... Y N Caogb

l...ah3: DCBe aUlA aChemistty a PregTesl O.SlIqJ.Screen 0 Other

P:rstISociallFamily HistOI)':c- _
X-R3y:

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Physical Exam:
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Nt
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Abo

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Ht:IldINeck 0 0
Skia
0 0
Eyes 0 0
Ears 0 0
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EI!r.mlllcs o 0

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Provider Signature
:>'1-108-2 01121104 Revised 10/{)4105

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U15 S. US Hwy 30I.SUmterl1ille. FL 335.15
(352) 793-5900. Fax (352) 793-9558
SUMTER COUNTY DETENTION CENTER

Today'sdnle:
History
o Scheduled
la-l~-\:3-
VISit 0 Unsdlc:duled 0 Ur;;cnl
ADULT ACUTE~~i~ N K;.....
_A _
Review of S]3telll3 (Necessary for Dd:UledlComp Eval)
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I 0 LI . Ll1zf; 1LWJ ch ~ Mood Cbaog<:sY N Leg SwdDDg Y N P.ioful UriD~tlo.n Y N
Wt:lkM •• d., Y\N Sbort o(B=tll Y N loiDlp.i"
, . Y N
Namboc::s Y N Cougb
Yt.3 t>EM~t..
Proeeda=:
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w.: a CBe aUlAa Chemistry tJ Preg TCIt o.sl,rq>.5creen a Other
".. '
.~ ' .
PastfSociallFamily History:
X-Ray:

. ~:S,q"\ Marlelll:ion;
~P Ur, &1S pP, RJLwtJ2&p3in__ 02Sat-----..:-
Nurse Signature: J:). 4l o~\\. ~.",d). vJ Mcds Reviewed:
Physlal Exam: \)
A!s<:ssmeDt:
Nl Abo
CeDenl j/ 0 f}a-c "13 6~ -~{21J1}Ud ~
n"'d/Neek 0 a
Sldn - 0 a
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a a
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Facility Name MonthlYear ~8:::~. _
HOUR 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 126 27 28 29 30 31
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RNlnil. START DATE STOP DATE

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ALLERGY
\\\kA -S:J1) ~ q~~1o ~
NURSE'S SIGNATURE INITIAL NURSE'S SIGNATURE INITIAL

DIAGNOSIS
~.R~~~~D\ ~(!..
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PATIENT
. NAME ~S(\~\\, 0 ~ ~.\ tlH~ liD Ilc9- _ f~{) IWINGI .
~

DOCUMENTATION CODEQ
DC - Discontinued
DO - Dose
H -Medical
Omitted
Hold
Order R - Refused
C - Court
LD - Lock Down
S - Self Administered
NS - No Show
0- Other
'd-~~~1 /.t11 . ~~\\~~r--
PHARMACY SUGGESTIONSIRECOMMENDATIONS DO NOT SUPERCEDE PHYSICIAN ORDERS
 "umter County Sherif:f,? Jffice
-Criminal Justice Operat.ons
Pbarmacy 3 Day Supply

Inmate N~ber: Zo I 2.'~0 0/ 2. Z 0

If you have been und~ the care of the jail physician. it is'recommended that you seek medical att"ention
froin a community provider. Continuance oftreabnent is advised to maintain your health an~ weallness.

If you are currently on prescribed medications you are instructed to continue your medications as c>rdered
by the j. hysician.. . .

fonoWing statemont and check the statement that applies:.

I have not been on any medications at the jaiL

---- I am on medications but do not want them at this time. 1 am aware olthe COnsequ8lllCes.

____ I am on medications and wish tocontinuCi thetp. I will follow up with my private doctor.
1 win report to ono oltho pharmacies listed below within 24 hours of my release. I
understand tbat I ~t report to tho pharmacy with a picture ID. and that medications
.. wl~ not be disponse4 to family or friends. •.
...- .. ...", ,"
•. •..•..

3lQ
Date
.•.•---------- .•--- .•.•-eut aJODglht,-O -- •. .• _

Patient's Name: Date of Release: _' ~_

Report to one of the p~acies below: .... .....

-----.~- - ---_.,-.---.-.
"---.::::.:::.::":.C:.: ,. "'-CCVS-PhmnliiCY" .- -- ..~... .... _:~~~::-~-~"'_-::::'.-::'::::::.. 7.~~_--.-:-...~:-_ :.~::::=:-=:-7::-:::::':-::---=-----'-:----": _... -:----:.-: - .'''''.'' ._.....
Thomas B. Langley Medical Center
420N. Main Street 1389 S. US 301
Bushnell, FL
Sumterville. FL
phone: (352) 793-8577
Phone: (352) 793-5900
..Hours: 8am - 5:30pm Mon. ~Fri.
Dear Pharmacist:
If the patient has been released from the Sumter County Detention Center in the last 24 hours. please call
the Medical Deparbnent to obtain and contion medical regime as ordered by the jail physician. Please
dispense a three (3) day supply of medication unless it is a narcotic.

Medical Department (352) 569-1720 or (352) 569-1118 Medical Department Hours: 5am _ 8p:an
Facility Name Month/Year _k_4_1.9-- _
.
HOUR 1 2 3 4 5 '6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
nQlOo
~~ ~OOJff'.& ~-\u.>~ ~~ I~ I
RN Injl.~f, START DATE lo _I q -I ~ STOP OAT "..1ll..Io-~l).I9--
01)00
j\x- '. .
C-~~~ \OM'\~ ~-t..u~Q..~~
lRoo
RN Inil. 'j.~ START DATE (0- \ q - 19-- STOP DATE lo - ~I')- la-
v

RN Inil. START DATE STOP DATE

RN Inil. START DATE STOP DATE

RN Inil. START DATE STOP DATE

RN Inil. START DATE STOP DATE

RNlnit. START DATE STOP DATE

RN Init. START DATE STOP DATE

,

RN Inil. START DATE STOP DATE

ALLERGY
~) \<1\
I
'500 b (}-14-_ io~
~.~R~~{)l
NURSE'S SIGNATURE INITIAL

8~
NURSE'S SIGNATURE INITIAL

DIAGNOSIS
,
,
'J
PATIENT
NAME

DOCUMENTATION
I\\()\~(\~ s\\\'O-l\\-
CODES),
I,
110 ,!J.,.I aRiD IWING b_ f>
DC - Discontinued Order R. Refused S - Self Administered
DO - Dose Omitted C - Court NS - No Show
H - Medical Hold LD - Lock Down 0- Other PHARMACY SUGGESTIONSIRECOMMENOATIONS DO NOT SUPERCEDE PHYSICIAN ORDERS
 . .--""_J
J

TUBERCULIN PPD

I .POD

lNITIALSKJN'IEST

DATE GIVEN: lo - \0 - I d DATE READ: til' 9 "I ~

SITE GIVEN: LeA-
-------- SIZE: =-G.. mm
LOT#: 3qlfq_~ _
NURSE: b ~~\\?O~6t=

I have received a fact sheet on TB and have had the opportunity to have my
questions answered. I agreed to TB testing by PPD. I understand the PPD skin test
mus be read 72 bours after being ad.miniStered. I have never had a positive
reacti n to a TB skin test, nor have I ever been treated with TB drugs.

Date

JJD7~\ lpt0 t3Y {Q- ~-I:A

Witness Signature
Date
~t••. 106 West 5th Ave
Wfi TECH CARE MOBILE X-RAY
.
Tallahassee, FL 32303
www.techcarexray.com
1!

RADIOLOGY REPORT

PATIENT NAME: VALDEZ, GILBERT PATIENT ID: 1220

FACILITY: SUMTER COUNTY DETENTION CENTER DATE OF BIRTH: 9/14/1968

REFERRING PHYSICIAN: VARGAS DATE OF SERVICE: 7/13/2012

EXAM: T SPINE 2V

REASON FOR EXAM:

FINDINGS:

VERTEBRAL BODY HEIGHTS ARE MAINTAINED. A SLIGHT LEVOSCLIOSIS IS PRESENT.

MARGINAL OSTEOPHYTES CAN BE SEEN ALONG THE MID TO LOWER DORSAL REGION. THERE
IS NO ACUTE COMPRESSION FRACTURE IDENTIFIED.
---------------
'----'...:.:

IMPRESSION:
MILD THORACIC SPONDYLOSIS.

Thank You for allowing us to participate in the care of your patient.

DICTATED & E-SIGNED BY John Carey Tomberlin, M.D. ON: 7/13/2012 5:02:46PM

PERSONAL & CONFIDENTIAL: If you have received this in error, please call (850)562-1656,
or fax (850)562-7209, and please destroy this document and/or delete this e-mail. .
~t••. 106 West 5th Ave
~ TECH CARE MOBILE X-RAY Tallahassee, FL 32303
fil
2 www.techcarexray.com
~

RADIOLOGY REPORT

PATIENT NAME: VALDEZ, GILBERT PATIENT 10: 1220

FACILITY: SUMTER COUNTY DETENTION CENTER DATE OF BIRTH: 9/14/1968

REFERRING PHYSICIAN: VARGAS DATE OF SERVICE: 7/13/2012

EXAM: PA AND LATERAL CHEST

REASON FOR EXAM:

FINDINGS:

THE HEART IS NORMAL IN SIZE. PULMONARY VASCULARITY IS UNREMARKABLE. THE LUNGS

ARE CLEAR. THORACIC SPONDYLOSIS IS NOTED.

IMPRESSION:
NO ACTIVE CHEST DIEASE.

Thank You for allowing us to participate in the care of your patient.

DICTATED & E-SIGNED BY John Carey Tomberlin, M.D. ON: 7/13/2012 5:01:35PM

PERSONAL & CONFIDENTIA/..: If you have received this in error, please call (850)562-1656,
or fax (850)562-7209, anc' please destroy this document and/or delete this e-mail.
 MEDICATION ADMINISTRATION RECORD Gife4.
•. • •
DIAMOND PHARMACY SERVICES
1.800.882.6337 FAX:724.349.2945

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ORIGINAL ORDER

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fl&i0;@OWI!~~~~~~%@~W~~~OO~~~.~~~~
il {;. i (I IV rJ ill (;) U!l 00 'If? 00 'YiJ ~ ill! iII it) 'l;lfli) tJi) ~ ~1 ~.liJ~ WJ W rw ~ .'l!i W
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 2, J 31

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ORIQlNAl ORDER

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

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ORIGINAL ORDER

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1~'~r~~W~~~OO~~~~~WTI~~~~~~~4~~~~m
I ,,~ ~y "I ~ ~ "1 1; ';:l '\l!: I~I ~ ,~J ~tj ".f!) il;' !~.lJ "~l ,It gt) l"~: ,~"'J ~J'~ ~,~ t~ ~.{~
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DIAGNOSIS
 ~~MTER COUNTYDETETNIONCEl'V.•e.'R
Medical "Sick Call" Slip

Inmate's Name: , M '[ L 6 EIZC Date:

Cell Assignment: Al.() k/tJ t tS-).. ...&1 Jail #: _

I am requesting medical attention because: Lvi H4Q t1f tI{ ,gal? AC[o.
Kt{L£-p. , 0" 1G l/-ftc 1(,J'14/bk 54/Ilf, T /U::JII&'I;[ 8..;..;c~/
FaerY/, hl5 r hE mv {-'F/U5 Vip ( C?Li7I-lJ.,{j 14,(/7'
(
-Sorey
I r r CiJ.,y ( IIIII rr; dtsu z,>,t'/I/t.o >(~/.(4V5
Qu,..!;!" At3uuJ s= 1~/Hk5 /1/"16 l:lf'o-Sf"r(( If5hd.U'rS-/I!L/
It;:slILrs 7

Inmate's Signature:

ReceiVing Officer & ID #:

Date: oif-t9-1' 2.

Medical Response or Action Taken:

Responding Nurse's Signature: d?t~L!A1 Wool Date: c9 ct<2 -/ C2..

Sick Call 03-020

Revised 8/05 Inmate's Medical File
 THOMAS E. LANGLEY MEDICAL CENTER
U25 S. US 301. Sumterville Florida 33585
(352) 793-5900. (888) 298-5510
Pharmacy Fax: (352) 793-7486

SUMTER COUNTY DETENTION CENTER

Date:
Time: am/pm

Person completing this form: _

Printed Name Signature

Please note that Schedule n prescriptions cannot be filled locally unless a DEA licensed prescriber manually signs a written
prescription that can be given to the dispensing pharmacy at the time of dispensing. Schedule n prescriptions must be filled for the
full quantity written.

Rx Name: Last
RxName: Last ~
First 0" .•.
llu"..;!;: MI First MI _
Inmate No: 18-~l~~ DOB 1--N-.-{p-Z- Inmate No: DOB _
Allergies: Allergies: _
~~M~ _

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;)?Jr;. .
T~ /JJJ-;
#620
ff'"a 0
Prescriber:
/~
Prescriber: _

Rx Name: Last _ RxNaJUe: Last _

First MI _ First MI _
Inmate No: DOB _ Inmate No: DOB _
Allergies: _ Allergies: _

Prescriber: _ Prescriber: _
Facility Name MonthNear 'J\l\"l f ZJ))Z
HOUR 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30131
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RN Init. START DATE STOP DATE

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RN Init. START DATE STOP DATE

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RN Init. START DATE STOP DATE

RN Init. START DATE STOP DATE

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RN Init. START DATE STOP DATE

RN Init. START DATE STOP DATE

ALLERGY
NURSE'S SIGNATURE INITIAL NURSE'S SIGNATURE

DIAGNOSIS
~~"--
PATIENT
NAME
DOCUMENTATION
\J <\\ ~'€7
CODES =
~n
(\ \ \

DC • Discontinued Order
DO - Dose Omitted
R - Refused
C - Court
S - Self Administered
NS - No Show
~ \fJtJ~~ X:t.fn~~tiO;1 hr)
H - Medical Hold LD - Lock Down 0- Other PHARMACY SUGGESTIONSIRECOMMENDATIONS DO NOT SUPERCEDE PHYSICIAN ORDERS
Facility Name MomhNear~~u~ne~Z_C~/=~=- _
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NURSE'S SIGNATURE INITIAL INITIAL
ALLERGY
-W'(J\. q-'~-lo~ ~URE
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DIAGNOSIS
!
PATIENT
NAME

DOCUMENTATION
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CODES =
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DC • Discontinued Order R - Refused S - Self Administered

DO - Dose Omitted C - Court NS - No Show
H - Medical Hold LD - Lock Down .O-Other 07~~C~G~T:SffiECOM::DATION~~~~~S ~
 THOMAS E. LANGLEY MEDICAL CENTER
1425 S. US 301 • Sumterville Florida 33585
(352) 793-5900. (888) 298-5510
Pharmacy Fax: (352) 793-7486

SUMTER COUNTY DETENTION CENTER

Date: Time: am/pm

Person completing this form: _

Printed Name Signature

Please note that Schedule II prescriptions cannot be filled locally unless a DEA licensed prescriber manually signs a written
prescription that can be given to the dispensing pharmacy at the time of dispensing. Schedule II prescriptions must be filled for the
full quantity written.

Rx Name: Last Rx Name: Last

Firs MI_~~ First
Inmate No:
Allergies:
DOB--3-llf~lO~
_
Inmate No: 'a,,; 1C1c9--.o
Allergies:
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Prescriber: (!&. f;4 Prescriber:
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Rx Name: Last _ Rx Name: Last _

First MI _ First ----------- MI ----
Inmate No: DOB _ InmMeNo: ------- DOB-----
Allergies: _ Allergies: _

Prescriber: _ Prescriber: _
 Thomas E. Langley Medical Center
1425 S. US Hwy 301 • Sumterville, FL 33585
(352) 793-5900 • Fax (352) 793-9558

SC JAIL - PERMISSION FOR TREATMENT

I, , vohll1tarily request
(please Print)
examination and/or treatment for myself by the personnel at Langley Medical Center. The
need for the examination and treatment, and the possibility of undesirable side effects, will be
explained by the employees oflLMC. I understand there is no guarantee or assurance, as to
the results which may be obtained, but normal prudent care will be exercised by employees or
lLMC concerning my diagnosis and treatment.

I authorize Langley Medical Center to release medical infomiation to another physician or

hospital to which I might be referred.

I certifY that the information given to Langley Medical Center is the truth, to the best of my
knowledge.

.Date:

,
.'

. ,
~-O19-2 09/30/05
 ':~'.
.;:< .

<
.'

niH Farmer
,'r .. Sheriff of Sumter County
2is East McCo)Jum Avenue, Post Office Box 188, Bushnell, Florida 33513

, "

SUfi.'ITERCOUNTY DETENTION CENTER

- MEDICAL DEPARTMENT
CLEAREANCE FOR WORK DETAIL
: .

,
Date:
", .
~(:.:

:.: .'

.:-;

\)()~~\.!lA ,
an 'nm",e "' 'he Snm'~ Coun,y De'entlo",
Center, is 11eT approved through this facility's Medical Department to participate in
the Work detail program. He/She is approved for the following assignment(s):

. (0ood Service
Ct.r1aundry
~aintenance
( ) Other:
-------

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...
.•.. ~ ...
'~
'

~~::~
-'-'
---
Ottice: (352) 793-0222/ Fax: (352) 793-0220 hIfP://www.sum.nel/sumlerso/ ".,
:

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 THOMAS E. LANGLEY MEDICAL CENTER
1415 S. US 301 • Sumterville Florida 33585
(351) 793-5900. (888) 198-5510
Pharmacy Fax: (351) 793-7486

SUMTER COUNTY DETENTION CENTER

Date: Time: amlpm

Person completing this form: _

Printed Name Signature

Please note that Schedule II prescriptions cannot he filled locally unless a DEA licensed prescriber manually signs a written
prescription that can be given to the dispensing pharmacy at the time of dispensing. Schedule II prescriptions must be filled for the
full quantity written.

Rx Name: Last RxName: Last _

Fin!t First MI _
hunateNo: hunate No: ------- DOB-----
Allergies: _~I:\
__ ~ Allergies: _
ERJ\ _
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~\e)<'{)'\) 10 Yn9
. ~\W\,~ ~~
.Q~\') -e- ~~ ~-, ~ O)\Q\W\t€. ~~ X 1cl~
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$14

Prescriber:

Rx Name: Last Rx Name: Last

First _ First
hunate No: _ hunateNo: -------
Allergies: _ Allergies: _

Prescriber: _ Prescriber: _

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