EFTA00059526¶
Bureau of Prisons Health Services Cosign/Review¶
Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Provider: Lab Result Receive Facility: NYM¶
Encounter Date: 07/10/2019 16:58¶
Cosigned by MD on 07/14/2019 18:12.¶
| BP-S358.060 | |
| SEP 05 |
MEDICAL TREATMENT REFUSAL¶
CDFRM¶
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.¶