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.

Name:

Electronic Signature:

Date:

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.

Electronic Signature:

Date:

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)

Please note, communications through our website or via email are not encrypted and are not necessarily secure. By submitting this form, you are granting Dr. Samieh Rizk, Manhattan Facial Plastic Surgery, PLLC, and/or Park Avenue Facial Surgery, PLLC, their employees, agents and assigns permission to review your photos. These photos will only be used in-house for consultation purposes.*

Our Recommended Accomodation

The Mark Hotel

Address:

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

Phone:

+1 212-744-4300

Distance to office:

0,9 mi 7 min
0,9 mi 7 min

The Carlyle, A
Rosewood Hotel

Address:

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

Phone:

+1 212-744-4300

Distance to office:

0,8 mi 5 min
0,6 mi 14 min

The Plaza Hotel
New York

Address:

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

Phone:

+1 212-759-3000

Distance to office:

1,8 mi 16 min
1,6 mi 37 min

The Lowell Hotel

Address:

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

Phone:

+1 212-838-1400

Distance to office:

1,5 mi 12 min
1,2 mi 29 min

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:

1,9 mi 13 min
1,4 mi 32 min

Our Location

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

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To schedule an appointment,
please call us at
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

Take a Tour

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.

Complete Registration Form Online

Parent / Guardian / Spouse Information

Health Questionnaire

Patient Acknowledgment

Photography Consent