<table><tr><th>From:</th><th>Lesley Groff</th></tr><tr><td>Sent:</td><td>Wednesday, January 21, 2015 8:01 PM</td></tr><tr><td>To:</td><td>Jeffrey Epstein; Karyna Shuliak</td></tr><tr><td>Subject:</td><td>Forms for Dr. Kline appointment tomorrow</td></tr></table>

I am sending you 2 forms that I have filled out but need your signature =or the Dr. Kline appt tomorrow at 8:40am. One is "Receipt of Notice =f Privacy Practices Written Acknowledgement Form" ...the other is a =93Patient Request for Email Communications" I am not sure if you =ant to sign either...

Karyna, can you please print for Jeffrey and let him have a look at =hem...if he wants to sign them, he can either take the originals with =im to the appointment tomorrow...or maybe better, you can fax them to =r. Kline's office at (you can always scan and email to =e and I can fax them if you prefer)

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