Exhibit,Appendix: Kristin Ballas v. New York Convention Center Operating Corporation d/b/a THE JACOB K. JAVITS CONVENTION CENTER

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                                FILED: NEW YORK COUNTY CLERK 03/24/2023 04:48 PM         INDEX NO. 152786/2023
NYSCEF DOC. NO. 7                                  RECEIVED NYSCEF: 03/24/2023




                    EXHIBIT E
FILED: NEW YORK COUNTY CLERK 03/24/2023 04:48 PM                                                                                                 INDEX NO. 152786/2023
NYSCEF DOC. NO. 7                                                                                                                         RECEIVED NYSCEF: 03/24/2023




               A M B U L

              Call Location:
              Last Name:                                                                              First Name:
              Home Add ess:
                                    G : 1                       Male (Circle                       Phone Number:        T
              DOB: Î 6
              Emerge   Contact/Phone Number:
                                                                                       Meds:
              Chief Complaint:
                                                                                       PMH:
              Allergies:
                                                                                                          2 a       Skin          Time:
              BP:              Res                 Pulse               il{L)
                                                                                                       02Sat:       Skin          Time:
              BP:              Resp:               Pulse:          Pupil[L)            (R)
                                                                                             Refusal of Treatme         Transportation
              CUPS Status:                                                                                                  to a hospital)and
                                                                                                    (treatment/transportation
                                                                                   Ihereby refuse
                 ective Assessment
                                                                                   1acknowledge     suchtreatment/transportationwasadviwdby
                                                                                       EMS    crewor  physician.
                                                                                                               I herebyreleasesuchpersonshoti.
                                                                                   the
                                                                                                                           expresswishm
                                                            C                      liability for respectingandfollowingmy
                                                                                    Patient Signature:

                                                                                   Witness Signature:


                                                                                                                                            c
              Commentary/Treatme




                                                                                               t                    9      Vred     _td
                                                  fu                 hos       _htal               Carc
                                       (2


              Presumptive            nosis:



              Physician Comments:




                imposition:
                                                                                 T a     fer of Care to
                                            Tr   at d and released


              Signature