Wiry 305 Cast 33.0 Witt Now Tort NY 100$ rt. 212.263.3030 fa. 212.2634092 rwloato.t :re F e I G PS - re IN1 0m• al astir - Consent for Diagnostic & Treatment Photographs I iralatssard eat pnotoilralas an or tier in wawa*. iiiiikuniultateri. deposer foss awskel latataill/PlflealtraonooTT by the phymetans of MU NOM Wi

rtment of Plastic Surgery 305 East 33rd Street New York, NY 10016 Tel. 212-263-3030 Fax 212-263-8492 Patient Name: Date of Birth: Consent for Diagnostic & Treatment Photographs I understand that photographs may be taken in connection with consultation, diagnostic testing, surgical procedures and treatments by the physician