EFTA00313964.pdf

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