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Patient Acknowledgment

We are required by law to maintain the privacy of protected health information and to provide individuals with our Notice of Privacy Practices which explains our legal duties and privacy practice with respect to protected health information. If you have any questions, please contact our Privacy Officer in person or by phone at (212) 452-3362.

Your signature below is only acknowledgment that you have received a copy of our Notice of Privacy Practices.

Photography Consent

I, , authorize Dr. Samieh Rizk, Manhattan Facial Plastic Surgery, PLLC, and/or Park Avenue Facial Surgery, PLLC, their employees, agents and assigns, to photograph and/or video me prior to, during, and after any surgery(ies) or procedure(s) that I have or may receive, and that such photographs, videos, reproductions and duplications shall become the property of Dr. Samieh Rizk, Manhattan Facial Plastic Surgery, PLLC, and/or Park Avenue Facial Surgery, PLLC.

I understand that the purpose of this authorization is for use in my medical records, and that by signing this consent I am not authorizing the use of my photographs or videos (or any reproductions and duplications thereof) for purposes of distribution, viewing at the office, use in scientific journals or posting on websites.

I, the undersigned acknowledge that I have received the following disclosures from the practice.

  • Facility Information
  • Patient Bill of Rights
  • Complaint Resolution Policy
  • Billing Information
  • Facility Ownership Disclosure
  • Information on Pain Assessment
  • Physician (s) Qualification
  • Photo Consent
  • Patient Acknowledgement (HIPPA Notice of Privacy Practices)

Our Recommended Accomodation

The Mark Hotel

The Mark Hotel

Address:

25 E 77th St, New York, NY
10075, United States

Phone:

+1 212-744-4300

Distance to office:

The Carlyle, A Rosewood Hotel

The Carlyle, A
Rosewood Hotel

Address:

35 E 76th St, New York, NY
10021, United States

Phone:

+1 212-744-4300

Distance to office:

The Plaza Hotel New York

The Plaza Hotel
New York

Address:

768 5th Ave, New York, NY
10019, United States

Phone:

+1 212-759-3000

Distance to office:

The Lowell Hotel

The Lowell Hotel

Address:

28 E 63rd St, New York, NY
10065, United States

Phone:

+1 212-838-1400

Distance to office:

The Gardens Sonesta ES Suites New York

The Gardens Sonesta ES Suites New York

Address:

28 E 63rd St, New York, NY
10065, United States

Phone:

+1 212-838-1400

Distance to office:

Contact Us

Our Location

1040 Park Avenue,
New York, NY 10028
212-452-3362

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212-452-3362

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Virtual Tour

Dr. Rizk's office is located on Park Avenue in Manhattan's premiere upper East side and has attained the JCAHO Gold Seal of Certification

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Out Of Town

Dr. Rizk has many patients who fly to his New York office for facial plastic surgery.

Fly-In For Surgery

WARNING: Dr. Rizk and his office do not offer any payment transactions on Instagram. For anything related to appointments or payments, please call the office or book an appointment through the website. This is the only official Instagram account of Dr. Sam Rizk click here. For all appointment and payment queries, please call the office or book an appointment through our website.