EAST R RIVE PC IMAGING, MEDICAL 10/14/2015 Date: JEFFREY EPSTEIN, Name: Patient RECORD INFORMATION PATIENT 0315192 #: Number Record Medical 090.44-3348 it: Security Social Apt/Unit/Suite: Address: E-Mait 00802 Zip: VI State: THOMAS SAINT City. it Phone Primary 01/20/1953 Birth: of Date below. boxes check the marking by information contact and physician referring your validate Please M.D. D. M W. BRUCE MOSKOWITZ Physician: Referring ❑ 33401 FL BEACH, PALM WEST 7100 SUITE DRIVE LAGLER N 11 Address: Physician's Referring ❑ Phone: Physician's Referring ❑ preference). (their CD and/or films reports, receive will procedure this ordered has that Physician referring Your other or yourself to processing additional any like would you if box check the In marking by indicate Please physicians Address: Name: Physicians Additional Address: To: Reports Additional ($200.00) Films & Report ❑ ($26.00) CD & Report ❑ Charge) (No Only Report ❑ Information Insurance it: Group Company. Insurance DOB: Insured's Name: Insured's patient: to Relation ID#: Insured's No ❑ Yes ❑ insurance? supplemental/secondary have you Do it: ID Insured's Company: Insurance yes, If No ❑ Yes ❑ visit? last your since changed insurance your Has receptionist.) desk front the to card(s) insurance new your supply and above Information insurance out fill please yes, (if TODAY EXAMS Accession Name Referring Code Exam Time / Pate 6784742 M.D W, BRUCE MOSKOWITZ, MRLSPNI EDT AM 10/14/20157:30 SERVICE OF TIME THE AT DUE IS PAYMENT Discover ❑ Amex ❑ Visa ❑ Mastercard ❑ Check ❑ Cash ❑ BALANCES. UNPAID ANY FOR RESPONSIBLE FULLY AM I THAT ACKNOWLEDGE HEREBY I Guardian: or Patient of Signature SLOZ1£L/LDO L N LL Nd 1823 Jame! leoPaN 643etal £LLbh£LZLZ EFTA00282926 EAST RIVER PC IMAGING, MEDICAL FORM FILMS/CD OUTSIDE 10/13/15 Date: JEFFREY EPSTEIN, Name: Patient 0315192 ft Number Record Medical you? with (films/CD) studies outside relevant any have you Do No ❑ Yes ❑ returned images outside your like would you how to as box the check please Yes, If you with back take and system our to CD Upload ❑ le fi on address home my to CD/Film Return ❑ physician referring my to CD/Film Return ❑ Signature Patient Name Receptionist Desk Front Signature Receptionist Desk Front atn5etui £LLhh£LZLZ 6/Z SLOZ1£L/LoO L 9Z LI- Vdd 1ss3 i t ianc ienIpaky EFTA00282927 EAST -RIVER PC IMAGING. MEDICAL RECEIPT OF ACKNOWLEDGEMENT PRACTICES PRIVACY OF NOTICE OF PC. Imaging, Medical River East from Practices Privacy of Notice the received have , JEFFREY EPSTEIN, I. SIGNATURE PATIENT 10/13/15 Medical River East of member staff a , I, signature, patient of lieu In Practices. Privacy of Notice current our given been has above named patient the that state PC Imaging, DATE SIGNATURE STAFF NAME PATIENT JEFFREY EPSTEIN, 0315192 JaAp Ropaky u!0etui £LLPPELZLZ 6/£ SL0Z/£L/L0O L '9Z LL Wd 18,33 i t EFTA00282928 ,EAST USE MEANINGFUL - HISTORY HEALTH PATIENT RIVER PC IMAGING, MEDICAL #:0315192 MRN JEFFREY EPSTEIN. Name: Patient Female ❑ Male It Sex: 01/20/1953 DOB: Years 62 Age: 10/14/2015 Date: Exam lbs Weight: nches Feet Height: Yes ❑ Language? Preferred your English Is language: preferred your specify please not, If No ❑ Latino or Hispanic Not ❑ Latino or Hispanic ❑ ethnicity? your Is What specify to not choose I ❑ Unknown ❑ race? your is What American African ❑ Alaskan Indian/ American ❑ Islander Pacific Hawaiian/ ❑ Asian ❑ Caucasian ❑ specify to not choose I ❑ Unknown ❑ Other ❑ status? smoking tobacco current your is What smoker day every Current ❑ smoker a Never ❑ unknown status Current ❑ smoker Former ❑ smoker day some Current ❑ smoked ever if Unknown ❑ medications? any taking you Are Dosage Dose) / (Name list: please so, If Name: Name: Name: No ❑ Yes ❑ Name: Name: Name: Dosage medications/drugs? following the of any to allergic you Are ❑ Penicillin ❑ Allergies Drug Known No ❑ Benadryl Versed ❑ Contrast) (iodinated Contrast CT ❑ Fentanyl ❑ ❑ Xanax ❑ (Gadolinium) Contrast MRI ❑ Epinephrine ❑ Sulfa ❑ Barium ❑ Other List Please allergies, Drug Other If forms? paper for opt you did Why forms paper prefer I ❑ iPad the offered not was I ❑ technology like don't I ❑ Other ❑ Papaw u!0etul LIPPELZLZ El 6/P Ise3 JaNei 2.0 v 2013 Form Use Meaningful SL0Z/£L/L°O L '9Z LL Nd EFTA00282929 EAST RIVER MAGNETIC PC IMAGING. MEDICAL. (MRI) IMAGING RESONANCE MRLSPNI Code: Exam 0315192 #: MRN JEFFREY EPSTEIN, Name: Patient 10/14/2015 Date: Exam lbs Weight: Inches Feet Height M Sex: Years 62 Age: 6784742 Acc# M.D. M.D. W, BRUCE MOSKOWITZ, Physician: Referring below. questions the of any to "YES" answer you if receptionist the notify Please IMPORTANT: response. your of technologist/radiologist the inform will receptionist The CHECK: PLEASE NO YES O ❑ O O O O YES O ❑ eyes? your from removed metal had you Have shrapnel? or BB's bullets, with shot been you Have pregnant? you Are nursing? you Are dialysis? peritoneal or hemodialysis on you Are inhaler? an or oxygen require you Do describe please yes If disease? renal have you Do items? metallic any wearing you Are when? yes, If imaged? be to area the on surgery Any heart? or brain ears eyes, your on surgery Any BODY? YOUR IN FOLLOWING THE OF ANY HAVE YOU DO Clips Brain/Aneurysm year make\ yes, if Defibrillator or Wires Pacer Pacemaker, Aids Hearing or Implants Ear Stimulators Electrical Implant/Prosthesis Pumps Infusion blood in Wires or Fitters Catheters. Coils. Replacement Joint or Limbs Artifical Eyeliner Tattooed Valves Heart Artificial implant of date provide please yes, If Stents Implants Dental Magnetic Patches Transdermal IUD implants future for expander Tissue Valves Mechanical or Pumps, Insulin Stimulators. Bone Shunts Programmable AIDS, HEARING Including objects metallic all remove must you room, MR the entering Before WARNING: piercing body barrettes, pins, hair beeper, phone, cell keys, watch, CARDS, CREDIT/BANK DENTURES, the consult Please clipper. nail and knife, pocket pens, cards, strip magnetic clips, money jewelry, room. MR the enter you BEFORE concerns or questions any have you if technologist 10/14/2015 Date: Name: Print Signature: Only Use Technologist's Complaint/Diagnosis: Patient NO ❑ YES ❑ area? this in studies imaging previous Any where? yes, If Number: Phone Des NO ❑ YES ❑ Reading Wet Technologist: 6/G 09-2013 Clueslionnake MRI iesipaw au!tiewi £LLPPELZLZ SLOZ1£LA3O L '9Z LL Nd Ise3 i t iann EFTA00282930 EAST -RIVER CARD AUTHORIZATION FILE/INSURANCE ON SIGNATURE PC IMAGING, MEDICAL SUBMISSIONS; INSURANCE MY ALL FOR FORM THIS OF USE AUTHORIZE I " COMPANY(S); INSURANCE MY ALL TO INFORMATION OF RELEASE THE AUTHORIZE I * BILL MY FOR RESPONSIBLE AM I UNDERSTAND I * OBTAIN ME HELPING IN AGENT MY AS ACT TO DOCTOR MY AUTHORIZE I * COMPANY(S); INSURANCE MY FROM PAYMENT AND DOCTOR: MY TO DIRECTLY PAYMENT AUTHORIZE I * ORIGINAL. THE OF PLACE IN USED BE TO AUTHORIZATION THIS OF COPY A PERMIT I * JEFFREY EPSTEIN, NAME PATIENT NUMBER: ID 10/14/2015 DATE: SIGNATURE• PATIENT ONLY: USE OFFICE FOR 0315192 MRN#: 02.2007 Form Flie on Signature JaNei leopavu au!betui £lLPPELZLZ 6/9 Isea SL0Z1£L/L3O L 9Z L4 INd EFTA00282931 EAST RIVER MAGNETIC PC IMAGING. MEDICAL (MRI) IMAGING RESONANCE MRLSPNI Code: Exam 0315192 #: MRN JEFFREY EPSTEIN, Name: Patient 10/14/2015 Date: Exam lbs Weight Inches Feet Height M Sex: Years 62 Age: 6784742 Acc# M.D. M.D. W, BRUCE MOSKOWITZ, Physician: Referring below. questions the of any to "YES" answer you if receptionist the notify Please IMPORTANT: response. your of technologist/radiologist the inform will receptionist The CHECK: PLEASE NO YES eyes? your from removed metal had you Have ❑ ❑ shrapnel? or BB's bullets, with shot been you Have ❑ ❑ pregnant? you Are ❑ ❑ nursing? you Are dialysis? peritoneal or hemodialysis on you Are inhaler? an or oxygen require you Do describe please yes If disease? renal have you Do ❑ ❑ items? metallic any wearing you Are ❑ ❑ YES DODO 0000000000000 when? yes, If imaged? be to area the on surgery Any heart? or brain ears eyes, your on surgery Any BODY? YOUR IN FOLLOWING THE OF ANY HAVE YOU DO NO Clips Brain/Aneurysm year make\ yes, if Defibrillator or Wires Pacer Pacemaker, Aids Hearing or Implants Ear Stimulators Electrical Implant/Prosthesis Pumps Infusion • blood in Wires or Filters Catheters, Coils. Replacement Joint or Limbs Artifical Eyeliner Tattooed Valves Heart Artificial implant: of date provide please yes, If Stents Implants Dental Magnetic Patches Transdermal IUD implants future for expander Tissue Valves Mechanical or Pumps, Insulin Stimulators, Bone Shunts Programmable AIDS, HEARING including objects metallic all remove must you room, MR the entering Before WARNING: piercing body barrettes, pins, hair beeper, phone, cell keys, watch, CARDS, CREDIT/BANK DENTURES, the consult Please clipper. nail and knife, pocket pens, cards, strip magnetic clips, money jewelry, room. MR the enter you BEFORE concerns or questions any have you if technologist 10/14/2015 Date: Name: Print Signature: DODO 0000000000000 Only Use Technologists Complaint/Diagnosis: Patient NO ❑ YES ❑ area? this in studies imaging previous Any where? yes, If Number: Phone Dr's NO ❑ YES ❑ Reading Wet Technologist: 09-2013 Questionnaire MRI LIPPELZLZ El 61L SLOZ1£L/LDO L '9Z LL Nd 1993 i t JaAp icoipaw EFTA00282932 am 7:30 10/14/15 EAST RIVER PC IMAGING, MEDICAL Questionnaire Experience Patient openly to opportunity an is This Questionnaire. Experience Patient Imaging Medical River East the to Welcome your about only questions- private any ask not will We experience. recent your about thoughts your share of level high the to services our strengthen us help will responses Your offices. medical our at experience patient. our as deserve you that expectation offices? Imaging Medical River East four our of one to visit rst fi your this Was 1. where) remember not do I but past, the in tests radiology had have (I Maybe o No o Yes o Imaging? Medical River East about hear you did How 2. (Google) Search Internet General o Visit Patient/Retum Existing o Physician Referring o Other: o Advertisement a Friend or Family o test(s)? your have you did office Imaging Medical River East Which 3. Level) (C Street 72nd East 523 (Bjearjgo Street 72nd East 523 o Street 72nd East 519 o remember not do I o Street 59th East 430 o Street 75th East 3 o Imaging? Medical River East to visit recent most your at done have you did test(s) What 4. Myelogram CT o PET/CT o CT o MR1 o Biopsy a Angiogram CT Coronary o Fluoroscopy / -Ray X o Mammogram o Ultrasound Breast Ultrasounob General o Placement Port o Scan Nuclear ❑ MRI Breast o Paracentesis a Thoracentesis o Insertion Line PICC o Scan Density Bone o Imaging Dental o Other o remember not do I o offi physician's referring your did or appointment your schedule member/friend family or you Did 5. physician/office My o appointment made friend/family A appoinhnerrb the made I o question. this skip please APPOINTMENT, MAKE NOT DID YOU If 6. being 10 and low extremely being 0 (with 10 to 0 of scale a on appointment, the made you If River? East at person scheduling the rate you would how high), extremely 10 9 8 7 6 5 4 3 2 1 0 Friendliness 10 9 8 7 6 5 4 3 2 1 Professionalism@ £LLbh£LZLZ 6/9 L4:9Z:IGL0Z/£1/OO Yid lae3 tonol iuo!Pati flugSewi EFTA00282933 arrived? you when manner friendly a in staff office front our by greeted immediately you Were 7. remember not do I ❑ No o Yes ❑ begin... test(s) your Did 8. late minutes 30+ ❑ late minutes 15-30 o late minutes 15 than Less ❑ Time of Ahead or On ❑ a provide technologist or staff office front coordinator, scheduling our did late, began test your If 9. explanation? reasonable remember not do I n No ❑ Yes o manner? clear a in test the of details the explain radiologist or technologist the Did 10. remember not do I ❑ No ❑ Yes o radiologist? or technologist the by test the throughout comfortable feel to made you Were 11. No ❑ Yes ❑ wou you that it is likely how Imaging, Medical River East at experience OVERALL your on Based 12. answer honest your provide Please colleague? or member family friend, a to office our recommend "n( being "0" and recommend" to likely "extremely being "10" with "10" and "0" between scale a recommend." to likely very 10 9 8 7 6 5 4 3 2 1 0 our at care medical of standard highest the receive you ensure to do can we that anything there Is 13. honesty. your appreciate We better? experience test your made have could What offices? experience, your regarding you contact to team management our of member a like would you If 14. name: your provide please E-mail: or Phone Preferred au!0etui £LLPPELZLZ 6/6 SLOZ1£L/L0O L '9Z LL Wd 18,33 iospoky EFTA00282934