EFTA00520760Set 9
4p2,724w
Prim* Care Physician' Existing Patiegt? /0)
..s , . No Primary Care Dentist
Physician First & Last /au Haar Olth.el Dentist First 8, Last Name p,.ofti,do _sraroacliaro
Addrep/ tri
Pahn ... Patient? 0 Yes u No Primary Care Dentist' Existing Patient? c Yes o No
Physician First & Last Name Dentist First & Last Name
Address ID/
IDS — Permanently disabled ... Patient? c Yes 0 No Primary Care Dentist' Existing Patient? a Yes a No
Physician First & Last Name Dentist First & Last Name
Address ID/
IDS — Permanently disabled
https://www.justice.gov/epstein/files/DataSet%209/EFTA00520760.pdf