iographs authorized: PM: • Prophylaxis authorized: Yes I No (Approval vaFrl 18 months from examination date) BWs: Panormc Pent Name: i 4sti Denblil t --1 9 . bps n , --)c-C-Vizy E Number. / 4 -n, 3 IQ: ()Sy MCC Institution: / NEW YORK Date: 7-2-6 Signature Block/Stamp: DDS. PDF Pres