rgent Referred to Sick Can: Radiographs authorized: PM: - Prophybcds 811 (Approval vaad 18 i No date) k Yes months from examination BWs: Panorer Patient Name: ,,-- $4Q n i -3 -e_c Thy E Dent; • -1 9. sir . ft , r Number 76 3 iSC OS-LI Institution: / MCC NEW YORK Date: 7— 24, Signa

nt Referred to Sick Call: Radiographs authorized: PM: Prophylaxis authorized: Yes I No (Approve; valid 18 months from examination date) EtWs: Panorer ;Pa ' nt Name: 7 s ---C4 . n i i e_ciVi*e_i f S Denfist Signature: 11 > DS gistli :rfitumber. 76 3 i e- Us-1/4i Institution: / MCC NEW YOR

ent Referred to Sick Call: Radiographs authorized: PM: Prophylaxis authorized: Yes 1 No (Approval valid 18 months from examination date) BWs: Panorer. Pagan Name:, S -1-C4 -3 —Cc-PR.-ti E n Dentist Signature: 0 - L1-44014LAA.4— >DS st r Number. f -7(, 31Se- USN Institution: / MCC NEW YORK

ent Referred to Sick Call: Radiographs authorized: PM: Prophylaxis authorized: Yes 1 No (Approval valid 18 months from examination date) BWs: Panorer. Pagan Name:, S -1-C4 -3 —Cc-PR.-ti E n Dentist Signature: 0 - L1-44014LAA.4— >DS st r Number. f -7(, 31Se- USN Institution: / MCC NEW YORK