EAST
RIVER
MEDICAL IMAGING. PC
OUTSIDE FILMSLCD FORM
Date: 5/30/18
Patient Name: EPSTEIN. JEFFREY
Medical Record Number # 0315192
Do you have any • levant outside studies (films/CD) with you?
O Yes No
tf Yes, please check the box as to how you would like your outside images returned
Upload CD to Our system and eke back with you
0 Return CCYFihn to my "ome address on .9le
0 Return CD/Film to my referring physioia-
Patient Sionatofe
Front Desk Regernonist
Front Desk Receptonist Signature
2000 ,1000Z TVA av Oble fiTinfOC/So
EFTA00313964