raphs PM: BWs Panore:c authorized: ' Prophylaxis authortzed: Yes I No (Approval valid 10 months from examination date) Patient Natra: , ,..-itit &kmi Dec-R--e_v £ Dentis -1 9. ITins E Nanbet: -76 LI-s r 3 i SC Us-`s Institution: / MCC NEW YORK Date: 7- 26 Signature Block/Stamp: IDS. PDF