THE FOLLOWING REQUEST IS FOR MEDICAL / DENTAL TREATMENT (Circle one)

DATE: __________________ NAME: _____________________________________________________________________________________________________

NIA #: _____________________________________________ ROSTER#: ______________________________________________ UNIT: _____________________________________________ THE FOLLOWING REQUEST IS FOR MEDICAL / DENTAL TREATMENT (Circle one) REASON FOR OFF-POST TREATMENT: ________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ DESTINATION: _____________________________________ DEPART DATE: _________________TIME: _______________RETURN DATE: _________________ TIME: _________________ APPROVED/DISAPPROVED COMPANY COMMANDER: ___________________________________________________________________________________ PRINT NAME SIGNATURE DATE The patient is required to wear civilian clothes when traveling away from the Kirkush Military Training Base. THE ABOVE INDIVIDUAL IS AUTHORIZED TO RECEIVE MEDICAL/DENTAL CARE FROM OFF-POST FACILITY APPROVED BY: NAME: ___________________________________________ RANK: ___________________________________________ SIGNATURE: _____________________________________ CMATT Coalition Military Assistance Training Team Kirkush, Iraq OFF POST MEDICAL/DENTAL TREATMENT FROM NIA IDENTIFICATION CARD