“—™" vu Langone MEDICAL CENTER Hansjorg Wyss Department of Plastic Surgery 305 East 33rd Street patenttame JEFFREY EPSTE;,) oateotartn:__ / 20 - |FS. Consent for Diagnostic & Treatment Photographs {understand that photographs may be taken in connection with consultation, diagnostic testing, surgical procedures and treatments by the physicians of NYU Plastic Surgery, Ors. Daniel Ceradini, Roberto Flores, Alexes Hazen, Jamie Levine, Eduardo Rodrigues, Pierre Saadeh, Sheet Patient/Guardian Signature Date To join, please provide us with your: [Please Print) Name: Email Address: Protecting your privacy is imporant to NYUPS and the ERPS. We keep your personal information confidential, We wil never share your information, it you wish to be called with our exciting offers please Telephone Number: 5) ®y checking this box, you agree we can Provided about our offers. Best time to call; CO 810m To unsubscribe from our emailing or call subject line. Date’ 4 ee InyUMC.org with the words “Unsubscribe Me* on the EFTA00313927