HARRY FISCH, MD (PIN #D91790) 944 Park Avenue New York, NY 10028 Patient Name: Sere Epsyeiy - Date of Birth: OFFICE VISIT New Patient Level I! New Patlent Level Ili Established Patient Visit Level I! Established Patient Visit Level III SURGICAL PROCEDURES Biopsy of Testis (Needle} Biopsy of Testis {incisional} Epididymovastostomy (Unilateral} Epididymovastostomy {Bilateral} Hydrocelectomy {Unilateral} Hydrocelectomy {Bilateral} sls|oja|e 421% i3./3.15 eiclals sisicicl2 BIW iala la clo |ZIiZIa ai/aAlo |e | 8/8 |2/2|2 oI1ciso << < —|~—/< < oelcl—|i—/9 =f[s|/eicie Sl=Sj=—/3/9 6/2 |8li=|a Slaelvia a} |2ie ein ig io S925 —F an —= DIAGNOSTIC TEST TO BE SCHEDULED Transrectal Prostate Sonogram Testicular Sonogram Testicular Sonogram w/Doppler Penile Duplex Doppler Bladder Ultrasound Cystoscopy CHARGE A O$/S6167¥ ID Number: *3Saaaaiiesed (212) 879-0800 Date of Service: / Of A / lis Unit Number: ULTRASONOGRAPHY DIAGNOSIS Acute Prostatitis PH 0 Hematuria Hydrocele [Testicular Failure AST | esticular Pain uC lVaricocele loluntary Sterilization RECEIVED I certify that | have rendered the above service: EFTA00304571