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Unit: 76318-054 NYM Z05 Screening encounter at Dental Clinic. Reason Not Done: Unavailable Comments: Patient has had several call outs for his Dental A & 0 screening but has not been escorted to Cosign Required: No Completed by Dental Asst on 07/19/2019 13:49. e dental clinic. Generated 07/19/201913

Referred to Sick Call: Radiographs authorized: PAs• . Prophylaxis auUtortzect Yes I No (Approval var 18 months from examination date) EPNs: Panorox iPc t Nan= i 9 4t, n -376 1-rite_ E. Dentist Si nature: 1,3" it 7‘ lisznben 3 IS= OS-1/4\ Institution: MCC NEW YORK Date: 7- 06 -1 9. Si

Unit: 76318-054 NYM Z05 Screening encounter at Dental Clinic. Reason Not Done: Unavailable Comments: Patient has had several call outs for his Dental A & 0 screening but has not been escorted to Cosign Required: No Completed by n 07/19/2019 13:49. e dental clinic. Generated 07/19/201913:49 by Burea

nt Retuned to Sick Call: Radiographs authorized: FAa- . Prophylaxis augtortzect Yes I No (Approval var 18 months from examination date) EPNs: Panorox iPc t Nemec i 9 Skin teS ti E Den' ! Nu isitsr _7‘ tsts.mben 3 I Sr- OSN Institution:/ / MCC NEW YORK Date: 7- 26 -1 9. Signature Block/St

Unit: 76318-054 NYM ZO5 Screening encounter at Dental Clinic. Reason Not Done: Unavailable Comments: Patient has had several call outs for his Dental A & 0 screening but has not been escorted to the dental clinic. Cosign Required: No Completed by Dental Asst on 07/19/2019 13:49. Generated 07/19/20191

nt Referred to Sick Colt Radiographs authorized: PM. . Prophylaxis authorizect Yes I No (Approval var 18 months from examination date) BW5: Panorox :ga t Narrar. , 9 SA.C.4 O -5;SV7 -42_ti 2- D ' I alur : 1)17-5 istur Number: i I \ Institution: / MCC NEW YORK Date: 7 .- 74 -19. /Stamp