I, Joseph R. Tigro, was diagnosed with high risk type Human Papillomavirus (HPV) on August 16, 2016. The test was completed by Robert Buka, MD. Anyone interested in obtaining information regarding the test or its results may submit a request, in writing, to Dr. Buka at: 220 Front Street, New York, NY 10038-2033. The written request can be submitted in any format acceptable to Dr. Buka, but should include at least the street address, e-mail address or PO Box that you request the information sent. Dr. Buka will provide this information at a time of his choosing, or within the time provided for in any policies and procedures. It is suggested, however, that information be sent within 2-3 business days or as determined by Dr. Buka.
I consent to the release of the information described above. Further, I release Dr. Buka, his agents, assigns, successors, representatives, and employees from any liability arising under the actions of Joseph R. Tigro, whether at law or in equity.
The “X” placed next to the name below is the equivalent of a signature in any jurisdiction.
_X_ Name: Joseph R. Tigro Dated: September 19, 2017