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11/19/2009 09:55 201-559-5081 TENAFLY PEDIATRICS

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FACSIMILE COVER SHEET

FROM: Jeffrey J Wild DAn;~ Wednesday, Noverrloer 11, 2009
65 Livingston AvenUt Roseland, NJ 0
973.59 DIRECT FAX: 973.597.2555
To: Dr. Russell asnes
FACSIMILE NUMUR: 12012618413 VOIC;f NUMBER:
TotAl, PAG~5 (WlTloi COVER): 04 Q_U;:NT NUMBEk: 99999/1 If you have any trouble with this transmittal, plea~e ~II 973.597. :2.554 (Jef!r,<;y J wild)

From Susa.n wild

D

Circular 230 Disclaimer: To ensure compliM~ with requirements imposed by the IRS, we Inform yol,l that any u.s. ~deral tall. i;ldvice contained in this communicationOnducfing My atta(hm~nts) 1~ not intended or written to be used, and cannot be used, for the purpose of (iJ avoiO'ing tax-related PEMlties under the Internal RevenlJe Code or Oi) promoting, marketing or rocommending to another party any transaction or tax'r~llIted m8tter(s} addre55ed herein,

This facsimile contillns priltil@ged and Confidential information. If you are not the intended recipient disserninationof this communication Is strictly prol'lfbited. If you hall!'! n~ceivea thiS f<lcsimUe In error, please immediately notify us by t€lephone and return the origiflalf<ilcsimile to the \lbove address. We will reImburse for aJl ~)(pen~~ incurred.

TENAFLY PEDIATRICS

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Fax Server

PHYSICIAN CERTIFICATION

To be compl~t9d ancJ 5igned by iiJ 1k!ft5ed physidan. PlEASE PRINT CUARL Y.

. PleilSe list immlJhizario!}$ on thi~ fDnn IP/het than B~ additlcmal met'3 of p.per.

Tni~ fgrm is int~nde<:l to ~ertify that your p.oent. . Dc.. "\.;=l? 'V\ \), 19 Il'1l!d!toally able to parti(j~atlj:ill the American Jewi~h World S~lYlo:::eCAJWS'') flrogrllm ~eKribed below ("Program""). As part crfthe Pl'Ogl1lm. your patil!!1lt may tr~vel to ~nd Visit an extremely rl.lral ~re~ with only rudimentary $;lt1it<lryf~ciJiti~s.· The wnditiol'l~ ~yr p;ltl~nt will fac~ wit! be: php'lcaUy ~nd mentally dem~nI:llng, Please complete this certification In Order to help U3 det~rmine your ~tl@nf ~ ~bility to part1dpat~ in the Program.

BRIEF DESCRIPTION OF PROGRAM:

TI:J~ Alternative I;IrO:I)k3 program is a s.ervlce-ihming program 11'1 Which gruups of Il1dMdl,l<llslive and "WOrk in rural Olmrntlnities. in various develapine- 'Quntrl~. Groups spend an !ver,;jll'" of &i;'; (6) ,",our:< a day working on OJ m~nuo1t I~bor project tnat cften includes a sl,nifieant amount ofbmding. kne.ellng ~nd heavy lifting, Though volun"p!:~rs take rt:gulaf w~ter and rot br~iilk5 d~rlng the work dilY. they work h3rd fer msnyhours each d~y, outside in ~x:tf.!me heat, under brir\lt sunlight, il'l of'rJ:!n dry and du~ty I!t'Ivitonmel1t~. Th~ ~otnm u "it'les in which the groups rive aretypitlllly within 30 minlite'> of a local clinic 3ncl within 3-5 hour$ ofi major hospital. A.l:cot'nmL)d,roons I!I~ h.l5tic and f<lOd is prepared by ii local cook, Tl'lp duration ranges from 7-11 d~~.

TO be completed by physkian/pril.ttitlcn~T:

HEAL Tlol foIISTORY:

Plea~ check the boxes next to each of the cendtlons your l'~t'<'i:nt has had in hi5/ho:r he~tth ni~ry: o Measles

n Chick~n F'O:x:

o G~tl"lal'1 Me.<;jl'~

o Ml.imps

LJ Hep;rtitl~ A o HepatitIs B D H epatltis C

t:I Rheumotlc FliNer D Substar'la!' ~bu~~ LI Akohol abus~

Cl M€rrtol dines.

o Social or behaviora I di~orde.rs

IMMUNIZATION HISTORY/DATES (DO NOT :a:ttach;! separilte pag!!)

PI~~i! check the bO)l; next to each of the immunizations your patlent h~$ had and inditn'l! the data (mm/yy) of immu"lzatlOr1:

o OPT

~~~~------------------------------------------------

D .PQlio OPV r?iilbit1) ~ ~~_~ _

~ MMR __

o Smiillipox

o 'T'1!;~"nlJ' &·~o-os~te-r--------------~---------~-----

o Hepatitis A ~ ~ _

o Hep;rtjti~ B

~ ~Ma~U~~T~~-t~(7~~~~~~la-5t~~-n~~-nd~r6-u~lt~J----------------~--~--------

Cl Men'rngitls_~ ~ ~

o Chicken Pox

o Fr@rt:vssis ---------------------------------

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.... .....

TENAFLY PEDIATRICS

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Fax Sarver

P~YlICi.n (ettifJGf.ion F'~g. ~ of.

o DIPhthl)rI;l ~ __ --- _

o VellowF<'II\"r~_ ........ __ ~ ~_~ _

o Typ~(lid ~ -

PATIENTS EMERGENCY M&OICAl NEEDS:

Does your patient wear a medic'll alen bracelet, or may patient otherwi$e reqUire emergency medical ca.r~ btcau~e ~.1n \md(>rlying medical condition? If so. ple,,~, ~x,pI~in nalure of p~tl@nt's medical condition, any h@alth restrictions USQd~tE<::I with that .:ondition. and the typ~ of ~ttl,=~~n~y ~oIIft that your patient may ~\,ire;

Doa your patient haw~ diabetes? If 50, are hi~/her activities restrict~d ;1'1 any w.~y? If $0, please e:.:plail1:

DQ!?$ your patient's blood typo!;! or Qther condition milk. p-;!tient lessame~~b(. tQ transfusion] Please txpl~ill.

I .. H)

Does your patient havNny ltnderlyinc or pre-existing mtdic;f conditions that m;y 'all fot emergency m@d{Cal tr@atYr\ll-nt ;1nd/or th~t AJVVS or tmergency care prllttrt/Qners should be aw.ift of (including in ~S~ ~ur p;rtient is

unable to cornmunleate fer him/he~lf)? _---: ~ ..,.....------~

Is your patient CUl'Terrtly under the me of a M'chl~trist or psychologi51 (if 1'51 please provJde n~me ilnd addMS)?

Is your p.<Iti!!nt currently StlfF~riT'1g from menta! h&llth. socia], or bel-JavlN.:I1 illnl!~se5 or disorders (or dOQ!: your patient hive II history of ~ny sUch illnesses or dl~rd~r£) that would Jmp.1;t hi;lh~r ability t¢ pattiripilte ~lJrc~fl)lIy in thE' F'rograrn or in i! grOl,lp or SDClal." v ironment (If se, pl~~ c:)Cp!eil)):

PATIENT'S KNOWN AlLEFlt;;IIOS (pil!lII)C indud~ .alkrgtes to medica1icn5);

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Tenafly Pediatrics

Patient Vaccine Administration Record

Name:

DOB:

WILD, DANIEL 04/28/1990 SEX: male

32 Franklin Street Tenafly NJ 07670

Add .. ess :310 MEADOWBROOK ROAD, WYCKOFF, NJ- 07481

Ins No:

No. Of Immunizations: 23
51 No. Vaccine Date GiVl!ln Dose
1. . Adacel 07/21/2009 0.5 ml
2. DT 06/24/2005
3. DTaP (#1) 07/03/1990 O.Sml
4. DTaP (#2) 09/17/1990 0.5 ml
5. DT~P (#3) 11/26/1990 0.5 ml
6. DTaP (#4) 11/05/1991 0,5 ml
7. OTaP (#5) 05/03/1995 0.5 ml
8. Hep A under 19 (#1) 07/31/2007 0.5 ml
9. Hep A under 19 (#2) 02/07/2008 0.5 ml
1O. HepatitisB (#1) OS/27/1998 0.5 ml
11. Hepatltls B (#2) 07/07/1998 O.S ml
12. HepatitisB (#3) 06/11/1999
13. Hib (#1) 11/26/1990 0.5 ml
14. Hib (#2) 02/05/1991 0.5 ml
15. Hib (#3) 04/01/1991 0.5 ml
16. Hib (#4) 07/08/1991 0.5 ml
17. IPV (#1) 07/03/1990 0.5 rnl
18. IPV (#2) 09/17/1990 0.5 rnl Lucation L arm 1M

Exp.Date

Given By L.MolkRN

L arm IM

L.Molk RN

http://lO.IOO.l.14:8080/mobiledocijsp/catalog/xml/printPatientsImmunizations.jsp?patien ... 11119/2009

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Tenafly Pediatrics

Patient Vaccine Administration Record

Name:

DOB~

WILD, DANIEL 04/28/1990 SEX: male

32 Franklin Street Tenafly NJ 07670

Address :310 MEADOWBROOK ROAD, WYCKOFF, NJ- 07481

Ins No:

No. Of Immunizations: 23
51 No. Vaccine Date Given Dose Location Exp.Date Given By
19. IPV (#3) 11/05/l991 0.5 ml
20. IPV (#4) 05/03/1995 0.5 ml
21. Menactra 06/24/2005 0.5 ml
22. MMR (#1) 07/08/1991 0.5 ml
23. MMR (#2) 05/03/1995 0.5 ml http://1O.100.1.14:8080/mobiledoc/j spl cataloglxml/printPatientsImmunizations-j sp?patien... 11/19/2009