months from examination date) £ Dentist nanl 1>Ds ignaturc Block/Stamp: Number: 76 3 IT- os-M PDF Institution: MCC NEW YORK Date: 7-26 Chret Dental Officer MCC New York Prescribed by P6400 Replaces BP-A0618 cf N 10 EFTA00073977 BP-S358 06O MEDICAL TREATMENT REFUSAL CDFRM SEP 05 U.S DEP