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Page 2405 Sa ee fon MEDICAL TREATMENT REFUSAL CDFRM U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS a 7-24-2019 Date |, 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. 2 eee Re EE RT RE Mr er The following treatment(s) was/were recommended: EYE DOCTOR EVALUATION. Se eee ee 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: orp nee os INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. oe eR eee en | 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 directions. (bMG}; (be HC) MD _7-24-2019 Counseled by Date S neenenaemt: myygmeeyne en nee ma caee NYM--NEW YORK MCC Signature of Witne KONG} (DMT HC) gee Se DOJ-OGR-00026081