Prophylaxis authorized: Yes I No (Approval valid 18 months from examination data) EtWw Panama ‘n Pa t Nam& s._-Qj n , "3"--e5V- -it E. Dentist Sinalere: C 4_44.4.44,4...A.Aial>17.5 r Number. ' 76 3 Æ 059 Insttrution: MCC NEW YORK Date: 7-U.--19. Signature Mock/Stamp: C. Ancrum Dot PØ Pres