.org submitting a message via MyChart, or by providing written notice to: NYU Langone Physician Services, PO Box 415662, Boston, MA 02241 Patient (Parent/Guardian) Signature Date EFTA00313915

, or its legal representatives, any and all such information. I AGREE that a photographic copy of this Authorization will be valid as the original. Parent/Guardian: Insurance Carrier: Address: Address: City/State/Zip: City/State/Zip: Home #: Policy/Medicaid: Work #: Claim Service #:

reatment involves the application of other chemicals, which may cause damage to my hair, skin. scalp. or other parts of my person Signature Date Parent/Guardian Consent ereby give my permission as parent or guardian of , who is years of age and is my , to receive the above referenced services at this

org, submitting a message via MyChart, or by providing written notice to: NYU Langone Physician Services, PO Box 415662, Boston, MA 02241 Patient (Parent/Guardian) Signature Date EFTA00308059 , NYU Langone Health HEALTH INFORMATION EXCHANGE, CARE EVERYWHERE AND HEALTHIX CONSENT FORM In this Consent For

pure barre 1237 Second Ave New York, NY 10065 CLIENT INTAKE Participant and/or Parent/Guardian Name: Karyna Shuliak Date of Birth: Email: Phone: Street Address: 301 E 66th Street City: New York State: NY How did you find out about us? If

oblem)? Any significant injury or accident (specify problem)? Would you like to discuss anything about your child's health with a school nurse? To Parent/Guardian: Please explain any "Yes" answers from above. I am the parent/guardian of the child named above. I give permission for the information on PARTS I an

oblem)? Any significant injury or accident (specify problem)? Would you like to discuss anything about your child's health with a school nurse? To Parent/Guardian: Please explain any "Yes" answers from above. I am the parent/guardian of the child named above. I give permission for the information on PARTS I an