IME OF SERVICE K Cash K Check K Mastercard K Visa K Amex K Discover I HEREBY ACKNOWLEDGE THAT I AM FULLY RESPONSIBLE FOR ANY UNPAID BALANCES. Signature of Patient or Guardian: £LLbh£LZLZ 643etal leoPaN Jame! 1823 Nd LL N L SLOZ1£L/LDO EFTA00282926 EAST RIVER MEDICAL IMAGING, PC OUTSIDE FILMS/CD FORM Da

TIME OF SERVICE El Cash 0 Check 0 Mastercaro 0 visa almex 0 Discover HEREBY ACKNOWLEDGE THAT I AM FULLY RESPONSIBLE FOR ANY UNPAID BALANCES. Signature of Patient or Guardian: 2000/T0002 XV 03:11 STOZ/OC/SO EFTA00313962

ME OF SERVICE 0 Cash 0 Check 0 Mastercard K Visa 0 Amex 0 Discover I HEREBY ACKNOWLEDGE THAT I AM FULLY RESPONSIBLE FOR ANY UNPAID BALANCES. Signature of Patient or Guardian: goon/noon WI xv OZ:9 STOZ/OC/SO EFTA00299773 EAST RIVER MEDICAL IMAGING, PC OUTSIDE FILMS/CD FORM Oate: 5/30/18 Patient Name: