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a. MEDICAL TREATMENT REFUSAL CDFRM
U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS
SSD
7-24-2019
Date
1, 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.
| understand the possible consequences and/or complications, listed above, and still refuse
recommended treatment. | 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.
MD
7-24-2019
NYM-—-NEW YORK MCC
at eee,
Se
ene rere th a
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