EFTA00138966¶
BP-A0618¶
JUN 16¶
U.S. DEPARTMENT OF JUSTICE¶
A&O DENTAL EXAMINATION (Initial Clinical Dental Findings)¶
FEDERAL BUREAU OF PRISONS¶
| Occlusion: | ||||
|---|---|---|---|---|
| Oral Hygiene: | Good | Fair | Poor | |
| CPITN: | 3 | 2 | 3 | |
| 3 | 2 | 3 | ||
| Head & Neck / Soft Tissue: | ||||
| D: 0 M: 1 F: 14 | Classification: CLI | |||
| Pain Scale: /10 | ||||
| Dental Prostheses at Intake: Yes Type: Age: Condition: | Comments: advanced mod to moderate gingival recession observed. Lower anterior crowding observed | ||
| Intra-oral Photos Taken: Yes No | Radiographs Taken: (Document findings on A&O encounter) Yes No | ||
| Instructed how to obtain urgent and non-urgent dental care: Yes √ No: | |||
| Treatment Priorities: | None: | Non-urgent: non-urgent | Urgent: Referred to Sick Call: |
| Radiographs authorized: PAs: ___ BWs: ___ Panorex: ___ | Prophylaxis authorized: Yes √ No (Approval valid 18 months from examination date) | ||
| Patient Name: Epstein, Jeffrey E | Dentist Signature: DDS | ||
| Register Number: 76318-054 | Institution: MCC NEW YORK | Date: 7-26-19. | Signature Block/Stamp: DDS. |
PDF¶
Replaces BP-A0618 of JUN 10¶
Prescribed by P6400¶
SDNY_00017330¶
Page 287¶
EFTA00138967¶
| BP-S358.060 | |
| SEP 05 |
MEDICAL TREATMENT REFUSAL¶
CDFRM¶
U.S. DEPARTMENT OF JUSTICE¶
FEDERAL BUREAU OF PRISONS¶
| 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.¶
SDNY_00017331¶
Page 288¶
EFTA00138968¶
| BP-S358.060 | |
| SEP 05 |
MEDICAL TREATMENT REFUSAL¶
CDFRM¶
U.S. DEPARTMENT OF JUSTICE¶
FEDERAL BUREAU OF PRISONS¶
| 7-10-2019 |
| 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:¶
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¶
SDNY_00017332¶
Page 289¶