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/06/2019 One Time TB Clearance: Yes Last PPD Date: 07/09/2019 Last Chest X-Ray Date: TB Treatment TB Follow-up Recommended: No Sickle Cell: Sickle Cell Trait/Disease: No Dualism Retails 66 y/o male 3 different stools Induration: 0mm Results: Sx free for 30 days: Yes Generated 08/10/2019 07:00 by RN Bure
ations, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental CO Won, and release the Buroau of Prisons and Its employees from any and all liability for respecting and f• owing my expressed wishes and directions. MD 7-24-2019 Counseled by Date Signature
/06/2019 One Time TB Clearance: Yes Last PPD Date: 07/09/2019 Last Chest X-Ray Date: TB Treatment TB Follow-up Recommended: No Sickle Cell: Sickle Cell Trait/Disease: No Dualism Retails 66 y/o male 3 different stools Induration: 0mm Results: Sx free for 30 days: Yes Generated 08/10/2019 07:00 by RN Burea
ations, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental CO 'Won, and release the Buroau of Prisons and Its employees from any and all liability for respecting and f• owing my expressed wishes and directions. 7-24-2019 Counseled by Dale e a is Sign
/06/2019 One Time TB Clearance: Yes Last PPD Date: 07/09/2019 Last Chest X-Ray Date: TB Treatment TB Follow-up Recommended: No Sickle Cell: Sickle Cell Trait/Disease: No Dualism Retails 66 y/o male 3 different stools Induration: 0mm Results: Sx free for 30 days: Yes Generated 08/10/2019 07:00 by Bureau o
ations, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental CO Won, and release the Buroau of Prisons and Its employees from any and all liability for respecting and f• owing my expressed wishes and directions. 7-24-2019 Counseled by Date a** si .nature
/06/2019 One Time TB Clearance: Yes Last PPD Date: 07/09/2019 Last Chest X-Ray Date: TB Treatment TB Follow-up Recommended: No Sickle Cell: Sickle Cell Trait/Disease: No Duration Petah 66 y/o male 3 different stools Induration: 0mm Results: Sx free for 30 days: Yes Generated 08/1 0/2019 07:00 by RN Burea
ations, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental CO 'Won, and release the Buroau of Prisons and Its employees from any and all liability for respecting and f• owing my expressed wishes and directions. 7-24-2019 Counseled by Dale a is Sign NYM
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