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any and all liability for respecting and following my expressed wishes and directions. MD 7-24-2019 Counseled by Dale Pa nes Sign r Date NYM--NEW YORK MCC EFTA00110339 BF-A0618 JUN 16 U.S. DEPARTMENT OF JUSTICE A&O DENTAL EXAMINATION (Initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS
3 14 15 16 m r- 0 32 31 30 2D 28 27 26 25 24 23 22 21 20 10 18 17 BP-A0618 JUN 18 U.S. DEPARTMENT OF JUSTICE A&O DENTAL EXAMINATION (initial Clinical Dental Findings) FEDERAL BUREAU OF PRISONS Occlusion: Oral Hygiene: Good Fair Poor CPFIN: 3 2- 3 3 2 — Head & Neck / Soft Tissue: D rt I F: Classifica
ility for respecting and following my expressed wishes and directions. 7-10-2019 Date Patie grtature Date NYM-NEW YORK MCC EFTA00050864 NYM--NEW YORK MCC 6P-5358.C60 MEDICAL TREATMENT REFUSAL C0E RM SEP 05 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF FRISONS 7-24.2019 Date I, JEFFREY EPSTEIN
institution: MCC NEW YORK • PDF Proscesod by RAM Replaces Bp-male of JUN 10 EFTA00050866 SP-A0818 A&O DENTAL EXAMINATION JUN 16 (initial Clinical Dental Findings) U.S- DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Ocdus!on: 5 1 2 3 4 5 8 7 e 0 10 11 12 13 14 15 18 § —2 3 31 30 28 28 27 28 25 212
-Pap Travel: Direct Travel: No Travel Restrictions: None UNIVERSAL PRECAUTIONS OBSERVED WHEN TRANSPORTING ANY INMATE: Transfer From Institution: NEW YORK MCC Phone Number: 6468366300 Address 1: 150 PARK ROW Address 2: City/State/Zip: NEW YORK, New York 10007 Name/Tale of Person Completing Form: Col
ature of Wines Date re‘ ee.tes p /res:ice a is Sign NYM--NEW YORK MCC Date ; EFTA00049323 BP-A0618 A&O DENTAL EXAMINATION JUN 16 (initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: • 1 2 3 4 5 8 7 6 9 1011 --- 32 CC 31 30 28 28 27 2825 24 23 22 1213 14
Pap Travel: Direct Travel: No Travel Restrictions: None UNIVERSAL PRECAUTIONS OBSERVED WHEN TRANSPORTING ANY INMATE: Transfer From Institution: NEW YORK MCC Phone Number. 6468366300 Address 1: 150 PARK ROW Address 2: City/State/Zip: NEW YORK, New York 10007 Namerfltle of Person Completing Form:
3 4 5 8 7 8 9 10 11 12 13 14 — 15 18 32 31 30 29 28 27 2825 21 23 22 21 20 19- 18 17 0 BP-A0618 A&O DENTAL EXAMINATION JUN 18 (initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: Oral Hygiene: Good Fair , 00, CPITN: 3 3 2- 9 Head & Nock / Soft Tissue
Pap Travel: Direct Travel: No Travel Restrictions: None UNIVERSAL PRECAUTIONS OBSERVED WHEN TRANSPORTING ANY INMATE: Transfer From Institution: NEW YORK MCC Phone Number. 6468366300 Address 1: 150 PARK ROW Address 2: City/State/Zip: NEW YORK, New York 10007 Namerfitle of Person Completing Form:
by Date a** si .nature of Witne s Date a is Sign NYM -N EW YORK MCC Date EFTA00105056 BP-A0618 A&O DENTAL EXAMINATION JUN 18 (initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Occlusion: 1 2 3 4 5 — 7 8 9 10 11 12 13 11 15 18 32 31 30 28 28 27 28 25 21 23 22 2
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