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6318-054 Date of Bldh: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: SRN Unit: H01 Date Initiated Esimat Handout/Tonic Copay Required: No Cosign Required: Yes TelophoneNerbal Order: No Completed by RN on 07/28/2019 07:22 Requested to be cosigned b
g /!: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/10/2019 16:58 Provider. Lab Result Receive Facility: NYM CosIgnod bye MD on 07/14/2019 18:12. &IMAM of Prisons • NYM EFTA00059496 BP-S358.060 MEDICAL TREATMENT REFUSAL CDFRM SEP C6 U.S. DEPARTMENT OF JUSTIC
h: 01/20/1953 Encounter Date: 07/28/2019 06:51 Sex: Provider: M Race: WHITE ME RN Reg #: 76318-054 Facility: NYM Unit: H01 Date Initiated Esimat Handout/Tonic Copay Required: No Cosign Required: Yes TelophoneNerbal Orden No Completed by RN on 07/28/2019 07:22 Requested to be cosigned by
g /!: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/10/2019 16:58 Provider. Lab Result Receive Facility: NYM CosIgnod bye MD on 07/14/2019 18:12. &IMAM of Prisons • NYM EFTA00132659 BP-S358.060 MEDICAL TREATMENT REFUSAL CDFRM SEP CS U.S. DEPARTMENT OF JUSTIC
: 76318-054 Date of Bldh: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: Unit: H01 Date Initiated Esimat Handout/Tonic Copay Required: No Cosign Required: Yes TelophoneNerbal Order: No Completed by on 07/2812019 07:22 Requested to be cosigned by
g /!: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/10/2019 16:58 Provider. Lab Result Receive Facility: NYM CosIgnod by on 07/14/2019 18:12. Bureau of Prisons • NYM EFTA00105055 BP-S358.060 MEDICAL TREATMENT REFUSAL CDFRM SEP CS U.S. DEPARTMENT OF JUSTICE
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