EFTA00139356


# Bureau of Prisons
Health Services
Modified Diet Request

# Types of Diets:

___ Clear Liquid Exp Date:
___ Low Fat Exp Date:
___ Mechanical Soft Exp Date:
___ Low Cholesterol Exp Date:
___ Low Triglyceride Exp Date:
___ Renal Exp Date:
___ Full Liquid Exp Date:
___ Sodium Controlled Exp Date:
___ Snack Exp Date:
___ Diabetic Exp Date:
___ Calorie Controlled Exp Date:

**X Other:** FISH ALLERGIES. Exp Date: 07/30/2020

Comments:

<table border="1"><tr><td></td><td colspan="2">MD</td></tr><tr><td></td><td colspan="2">Health Service Staff</td></tr><tr><td>EPSTEIN, JEFFREY EDWARD</td><td>76318-054</td><td>07/30/2019</td></tr><tr><td>Inmate Name</td><td>Reg#</td><td>Date</td></tr></table>

Generated 07/30/2019 14:57 by

MD

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Bureau of Prisons - NYM

CONFIDENTIAL



SDNY_00009452