EFTA00138966

BP-A0618

JUN 16

U.S. DEPARTMENT OF JUSTICE

A&O DENTAL EXAMINATION
(Initial Clinical Dental Findings)

FEDERAL BUREAU OF PRISONS

<table><thead><tr><th rowspan="2"></th><th colspan="4">Occlusion:</th></tr><tr><th>Oral Hygiene:</th><th>Good</th><th>Fair</th><th>Poor</th></tr></thead><tbody><tr><td rowspan="2">CPITN:</td><td>3</td><td>2</td><td>3</td><td></td></tr><tr><td>3</td><td>2</td><td>3</td><td></td></tr><tr><td colspan="5">Head &amp; Neck / Soft Tissue:</td></tr><tr><td rowspan="3">D: 0<br>M: 1<br>F: 14</td><td colspan="4">Classification:<br>CLI</td></tr><tr><td colspan="4">Pain Scale:<br>/10</td></tr></tbody></table>

<table><tr><td colspan="2">Dental Prostheses at Intake:
Yes
Type:
Age:
Condition:</td><td colspan="2">Comments: advanced
mod to moderate gingival recession observed.
Lower anterior crowding observed</td></tr><tr><td colspan="2">Intra-oral Photos Taken:
Yes
No</td><td colspan="2">Radiographs Taken: (Document findings on A&amp;O encounter)
Yes
No</td></tr><tr><td colspan="4">Instructed how to obtain urgent and non-urgent dental care: Yes √ No:</td></tr><tr><td>Treatment Priorities:</td><td>None:</td><td>Non-urgent:
non-urgent</td><td>Urgent: Referred to Sick Call:</td></tr><tr><td colspan="2">Radiographs authorized:
PAs: ___
BWs: ___
Panorex: ___</td><td colspan="2">Prophylaxis authorized: Yes √ No
(Approval valid 18 months from examination date)</td></tr><tr><td colspan="2">Patient Name:
Epstein, Jeffrey E</td><td colspan="2">Dentist Signature:
DDS</td></tr><tr><td>Register Number:
76318-054</td><td>Institution:
MCC NEW YORK</td><td>Date:
7-26-19.</td><td>Signature Block/Stamp:
DDS.</td></tr></table>

PDF

Replaces BP-A0618 of JUN 10

Prescribed by P6400



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EFTA00138967

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| :--- | :--- |
| BP-S358.060 | |
| SEP 05 | |

MEDICAL TREATMENT REFUSAL

CDFRM

U.S. DEPARTMENT OF JUSTICE

FEDERAL BUREAU OF PRISONS

<table border="1"><tr><td>7-24-2019</td></tr><tr><td>Date</td></tr></table>

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.









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EFTA00138968

| | |
| :--- | :--- |
| BP-S358.060 | |
| SEP 05 | |

MEDICAL TREATMENT REFUSAL

CDFRM

U.S. DEPARTMENT OF JUSTICE

FEDERAL BUREAU OF PRISONS

<table border="1"><tr><td>7-10-2019</td></tr><tr><td>Date</td></tr></table>

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:

66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR.

The following treatment(s) was/were recommended:

CHEST X-

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:

WORSENING THE CONDITION IF THERE IS ANY FINDINGS

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.











NYM–NEW YORK MCC





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