pat\ 11:U Langone MEDICAL CENTER Heis.pm Wyss Department of Plastic Surgery 305 East 33rd Street New York, NY 1001 Patient Name: 5 eFficel — GPs-reiNI Date of Bette --cz Cl - 19 SS Consent for Diagnostic & Treatment Photographs I understand physicians that photographs may be taken vi connection with consultation. diagnostic testing. surgical procedures and treatments by the Sharma. of NYU Plastic Surgery, Drs. Daniel Cern:MI. Roberto Fares, Mesas Hazen, Jamie Levine, Eduardo Rodriguez, Pierre Saadeh, Shoe baud Stoltenberg, VEshal Thanlk, and Barry Zede or the Nine PractitionersAmanda Young, Kimberly Monona, Whitney Sala and NEcole Sweeney 1 understand that failure to consent to these photographs wawa NYU Plastic Surgery the right to decline my treatment erAS-reu--I Print Patient/Guardian Name Patent/Guardian Signature Relationship to Patient Date Email / Call Consent , Reconstructhe Join our online newsletter to receive anhouncements, news and learn about mein offers at NYU PIBSIAC Surgery and The institute of Plastic Surgery. To 'on, please provide us with your 'Please Print/ Name'. Final Address. Prolettre iw pr/racy us nponant to Nn e5 and the eltPS. We str If you wish to be called with our earltIng offers Please Telephone Number o keep your pencrol rdormshon cOarilJeltoi wei rear Mare your utinnapart. 4 1sest number to call you. By checking this boa. you agree we can lea a message at the numbbi provided about our offers Best time to till: Q11-10am /0 12pm - 2pm Q 4 1 To subject unsubscribe horn out emailIng or call ( a, please Send an email to NYUPIastkSu'tteryponimc.org with the words linsubscribe me on the line. / / N..,.,.. Date' .Signature EFTA00313927