EFTA00134765¶
Bureau of Prisons Health Services Cosign/Review¶
Inmate Name: EPSTEIN, JEFFREY EDWARD Date of Birth: 01/20/1953 Sex: M Provider: Lab Result Receive Reg #: 76318-054 Race: WHITE Facility: NYM¶
Encounter Date: 07/10/2019 16:58¶
Cosigned by 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.¶
Counseled by Date¶
Patient’s Signature Date¶
Signature of Witness Date¶
NYM—NEW YORK MCC¶
EFTA_00000232¶