Aaa EAST RIVER MEDICAL IMAGING, PC OUTSIDE FILMS/CD FORM Oate: 5/30/18 Patient Name: EPSTEIN, JEFFREY Medical Record Number # 0315192 Do you have any t outside studies (films/CD) with you? O yes No / Wf Yes, please check the box as to how you would like your outside images returned @ Upload CD to our system and take back with you 0 Return CD/Film to my home address on file OC Return CD/Film to my referring physician Front Desk Receptionist aa Front Desk Receptionist Signature £000/2000 XYvd KV 02:8 STOZ/0C/S0 EFTA00313964