EFTA00059521

U.S. DEPARTMENT OF JUSTICE

MEDICAL TREATMENT REFUSAL
CDFRM

7-24-2019
Date

I, JEFFREY EPSTEIN 76318-054, refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s):

DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY:

EYE DOCTOR EVALUATION.

The following treatment(s) was/were recommended:

EYE DOCTOR EVALUATION.

Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment:

INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES.

I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions.

Counseled by
MD 7-24-2019
Date

Patient's Signature
Date

Signature of Witness
Date
NYM—NEW YORK MCC