Epstein's refusal of a recommended eye doctor evaluation at MCC New York

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¶