SCHAFFER, SCHONHOLZ & DROSSMAN. LLP — BREAST MRI 315 West 57th Street (between 8TH Avenue and 9" Avenue) Tel: New York. New York 10019 Fax: PATIENT'S NAME

may be administered during your MRI examination. If you have any questions or concerns, please call our office at EFTA00520769 Patient's Name: SCHAFFER, SCHONHOLZ & DROSSMAN, LLP 488 Madison Avenue • New York, NY 10022 31! West 57" Street • New York, NY 10019 PRE-CERTIFICATION INFORMATION DOB: I