. Rev. 412018 EFTA00520773 SCHAFFER, SCHONHOLZ & DROSSMAN, LLP 315 West 57th Street - LL4 New York, NY 10019 Tel: Fax hi PAIIENNgiagg.Bablic,rcz%:" ; ';;; , ' tt‘le;; t3.;;', Patient Name: Medical Record #: Date of Exam: Referring Dr.: Date of Birth: Age: Height: Weight: O Male O Fema