EFTA00059453

Bureau of Prisons
Health Services
Modified Diet Request

Types of Diets:

___ Clear Liquid Exp Date:
___ Low Fat Exp Date:
___ Mechanical Soft Exp Date:
___ Low Cholesterol Exp Date:
___ Low Triglyceride Exp Date:
___ Renal Exp Date:
___ Full Liquid Exp Date:
___ Sodium Controlled Exp Date:
___ Snack Exp Date:
___ Diabetic Exp Date:
___ Calorie Controlled Exp Date:
X Other: FISH ALLERGIES. Exp Date: 07/30/2020

Comments:

EPSTEIN, JEFFREY EDWARD
Inmate Name
76318-054
Reg#
Date

MD
Health Service Staff

07/30/2019