EFTA00139326


BP-A0618

JUN 18

U.S. DEPARTMENT OF JUSTICE

A&O DENTAL EXAMINATION
(Initial Clinical Dental Findings)

FEDERAL BUREAU OF PRISONS

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

Register Number: 76318-054

Institution: MCC NEW YORK

Date: Signature Block/Stamp:

Prescribed by P6400

Replaces BP-A0618 of JUN 10

CONFIDENTIAL



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