Dr. Jeremy Green 12/31/2014|
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City of Miami Beach, ln0 Convention Center Drive, Miami Beach, Florida 33139,
OFFICE OF THE CITY CLERK, Rafael Granada,City Clerk
Tel: (3O5)b7374ll' Fax: (305)hr3-7254
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02-14-2014
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Dr. Jeremy Green
1415 20th Street
Miami Beach, Florida 33139
Health Advisory Committee
Congratulations! You have been appointed b«the City Commission to the agency,
board mr committee named above for a term ending: 12/31/2014.
Pursuant to Ordinance No. 2006-3543, commencing with terms beginning on or after
January 1, 2007, the term of board members who are directly appointed by a member of
the City Commission shall automatically expire on [)eoernbmr 31 of the year the.
appointing elected official leaves.
If you are unable to accept this appointment or have any questions, please call the City
Clerk's Office at3O5-873-7411. Please read the enclosed materials carefully.
Congratulations again and good luck.
Sincerely,
`~~~-
Rafael E. Granadm
City Clerk
cc: Saul Frances, Parking Director
Sonia Bridges
ATTACHMENTS:
Letter ofAppointment
Oath
City Code/Ordinance section applicable to agonoy, board or committee
City Code Section 2-22, 2'23, 2-24, 2-25, 2'26' 2-458 and 2-458
Ordinance No. 2OO8'3543-Amendment ho City Code Section 2-22
Miami-Dade County Code Section 2-11.1 -Conflict of Interest and Code of Ethics Ordinance
City Wide Permit Application ' (Parking Department Form)
Booklet'Guide to the Sunshine Amendment and Code ofEthics for Public Officers and Employee
We are committed to providing excellent public service and safety to all who live, work and play a our vibrant, tropical, historic community.
MIA/01BEACH
City of Miami Beach,1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachfl.Qov
OFFICE OF THE CITY CLERK,Rafael Granado,City Clerk
Tel:(305)673-7411,Fax:(305)673-7254
TO: Dr. Jeremy Green
RE: Health Advisory Committee
I do solemnly swear or affirm to bear true faith, loyalty and allegiance to the Government of the
United States, the State of Florida, and the City of Miami Beach, and to perform all the duties of
a member of the above-mentioned board or committee of the City of Miami Beach to which
have been appointed for a term ending: 12/31/2014.
I have been issued a copy of Section 2-11.1 of the Miami-Dade County Code(Conflict of Interest
and Code of Ethics Ordinance), as well as the Florida Commission on Ethics Guide to the
Sunshine Amendment and Code of Ethics for Public Officers andunderstand that as a member of
a City of Miami Beach Board and/or Committee, I must comply with the financial disclosure*
requirements of Miami-Dade County or the State of Florida (depending on the board or
committee on which I serve) on July 1 st, following the closing of the calendar year on which I
have served.
Dr. Jeremy Green
�
Sworn to and subscribed before me this day of XA
X2014
Silvia Prieto
Deputy Clerk
*Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and
Committees for additional information regarding the Financial Disclosure Requirements.
We are mm tted to��r�v�idpng a 911ent�ubic� ervi�ce and afety to al,w�►o�live;ogn'aar�d lay invour�vlbrano�t a�i�al�lh�stori nco�mmunity.
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MIAMIBOARD AND COMMITTEE APPLICATION FORM
cdgl� - 8
Last Name. First Name Middle Initial
i
STYL E�1 0 3 Al I A eA 1 93)55
Home Address City State Zip Code
3�S -�0�6 Y 30��1Y3 I fiE4 y 6A& Ai M b 6&M A I L.
Home Telephone Work Telephone Cellular Telephone Email address
�anl 'f 1� "A-TDtylrY �11GG/41el �M tax.-06:1 S f
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�c�2 poi Z rJ BLV STr 2oa 60d4t—�,4TC6S c 3 3/yL
Business Address G City State Zip Code
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Please.attach a copy of currently effective professional license.
Pursuant to City Code section 2-22(4)a &b: Members of agencies, boards and committees shall be affiliated with the City;
this requirement shall be fulfilled in the following ways: a. An individual shall have been a resident of the City for a minimum of six
months; or b. An individual shall demonstrate ownership/interest for a minimum of six months in a business established in the City
for a minimum of six months.
e Resident of Miami Beach for a minimum of six(6)months: Yes Sor No
e Demonstrates ownership/interest in a business in Miami Beach for a minimum of six months:Yes G or No La
e Are you a registered voter in Miami Beach: Yes M or No La
e I am now a resident of: North Beach ID South Beach U Middle Beach
e I am applying for an appointment because I have special abilities,knowledge and experience. Please list below:
e Are you presently a registered lobbyist with the City of Miami Beach?Yes U3 or-No
Please list your preferences in order of ranking ['I] first choice[2] second choice, and [3] third choice. Please note that
onl three 3 choices will be observed b the Ci Clerk's Office.
❑Ad Hoc Charter Review and Revision Board 0 Debarment'Committee 0 Miami Beach Human Rights Committee
0 Ad Hoc Committee Centennial Celebration O Design Review Board* O Miami Beach Sister Cities Program
❑Ad Hoc Committee Flooding Task Force 0 Disability Access Committee 0 Normandy Shores Local Government
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Committee
0 Committee on the Homeless 0 Housing Authority ❑Sustainability Committee
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❑Community Development Advisory Committee 0 Madne:Authorit ❑Transportation and Parkin Committee
❑Community Relations Board 0 Miami Beach Commission for Women ❑Visitor and Convention Authority
0 Convention Center Advisory Board ❑Miami Beach Cultural Arts Council 0 Youth Center Advisory Board
"0 Waterfront Protection Committee
* Board members are required to file Form 1 —"Statement of Financial Interest"with the State.
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Page 1 of 4
F:ICLEM$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION 46 BOARDS 12.16-2013.doc
' 1
°° Note:If applying for Youth Center Advisory Board,please indicate your affiliation with the Scott'Rakow Youth:Center:.
1. Past service on the Youth Center Advisory Board:Yes LJ No Dates of Service:
2. Present participation in Youth Center activities by your children:Yes No
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Child's name: Age: Program:
Child's name: Age: Program:
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•Do you currently have a violations)of City of Miami Beach Code?Yes Uor No541f yes,please explain in detail:
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Name Position
Name Position
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901"S
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• Pursuant to City Code Section 2-25 (b): Do you have a parent spouse child.Z brother Z or.sister 3 who is
employed by the City of Miami Beach?Check all;that apply.
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What Is your race?
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Page.2 of 4
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION 46 BOARDS 12-16-2013.doc
Do you consider yourself to be Spanish,Hispanic or Latinola?.Mark the"No"box if not Spanish, Hispanic,.Latino/a..
EINO
0 Yes
Do you consider yourself Physically Disabled?
II—�� o
4�Yes
NOTE:IF APPOINTED,YOU WILL BE REQUIRED TO FOLLOW CERTAIN LAWS THAT APPLY TO CITY BOARD/COMMITTEE
MEMBERS.THESE LAWS INCLUDE,BUT ARE NOT LIMITED TO:
• Prohibition from directly or indirectly lobbying City personnel(Miami Beach City Code section 2-459).
• Prohibition from contracting`with the City(Miami-Dade County Code section 2-11.1.).
• Prohibition from lobbying before the board/committee you have served on for period of one year after leaving office(Miami Beach
City Code section 2=26).
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• CMB Community Development Advisory Committee: prohibition, during tenure and for one year after leaving office, from having
any interest in or receiving any benefit from Community Development Block Grant funds for either yourself, or those with whom
you have business or immediate family ties(CFR 570.611).
o Sunshine Law - Florida's Government-in-the-Sunshine-Law was enacted in 1967. Today, the Sunshine Law regarding open
government can be found in Chapter 286 of the Florida Statutes. These statutes establish a basic right of access to most
meetings.:of.boards,commissions and other governing bodies of state and local.govemmental agencies or authorities.
o Voting conflict–Form 8B is for use by any person serving at the county,city or other local level of government on an appointed or
elected.board, council,%commission, authority or committee. If applies.equally to members of advisory.and non-advisory bodies
who are presented.with a voting conflict'of interest under Section 112:3143, Florida Statutes.
Upon request,copies of these laws may be obtained from the City Clerk.
I HEREBY ATTEST TO THE ACCURACY AND TRUTHFULNESS OF THE APPLICATION; AND I HAVE RECEIVED, READ AND
WILL ABIDE BY CHAPTER 2, ARTICLE VII, OF THE MIAMI BEACH CITY CODE, ENTITLED"STANDARDS OF CONDUCT FOR
CITY OFFICERS,EMPLOYEES AND AGENCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND
STATUT ACQ
g.0 INGLY.'
cant' gnature Date Name of Applicant(PLEAS`E'PRINT)
Office b
Received m the.City Cler k's y
N e of Dep-utytlerk Control No. D e
PLEASE REMEMBER TO ATTACH A CURRENT RESUME, PHOTOGRAPH AND A
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ATTACH ADDITIONAL SHEETS, IF NECESSARY, TO PROVIDE REQUIRED
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Page 3 of 4,
F:\cLER\$ALL\BFORMS\BOARD AND COMMITTEES\BC APPLICATION 46 BOARDS 12=16-2013.doc
JEREMY BLAIR GREEN,MD,FAAD
4425 Ponce de Leon Blvd.Suite 200
Coral Gables,FL 33146
305.443.6606(p)305.443.4890(f)
www.drfredricbmndt.com
www.youtube.conVuser/jeremygreenmd
1. EDUCATION
07/01/2010–06/30/2011 SkinCare Physicians,Chestnut Hill,MA,Fellowship in Laser,Surgical,and Cosmetic
Dermatology.Mentors Clinical Faculty at Harvard and Yale Departments of Dermatology
07/01/2007–06/30/2010 University of Miami Miller School of Medicine,Miami,FL Resident,Department of
Dermatology&Cutaneous Surgery
06/21/2006-06/30/2007 Mount Sinai Medical Center,Miami Beach,FL
Intern,Internal Medicine
06/18/2004–05112/2006 University of Miami Miller School of Medicine,Miami,FL MD,Alpha Omega Alpha
(AOA)
08/30/2002–06/17/2004 Northwestern University Feinberg School of Medicine,Chicago,IL,MD Candidate
08/1997–06/2001 Princeton University,Princeton,NJ
AB in History of Science,Cum Laude
ll. APPOINTMENTS
08/201 1–Present University of Miami Department of Dermatology&Cutaneous Surgery/Jackson
Memorial Hospital,Miami,FL
Voluntary Assistant Professor of Dermatology,attending for staff clinic providing patient care
and resident education.
07/2011–Present Dr.Brandt Dermatology Associates
4425 Ponce de Leon Blvd.,Suite 200,Coral Gables,FL
Full-time staff dermatologist.
07/2011–Present Dermatology Research Institute,LLC
4425 Ponce de Leon Blvd.,Suite 200,Coral Gables,FL
Performs,as principal and sub-investigator,FDA-approved clinical trials for dermatology
procedures for pharmaceutical,biomedical,and cosmetic device companies.
2010–06/2011 New England Baptist Hospital,Boston,MA
Staff dermatologist,inpatient consultations.
2010–06/2011 Codman Square Health Center,Dorchester,MA
Staff dermatologist for community health center affiliated with Boston Medical Center and
Boston University Department of Dermatology serving Haitian-American and Hispanic
population.
III. CERTIFICATION/LICENSURE
2012—Present Fellow,American Academy of Dermatology
2010—Present Diplomate,American Board of Dermatology
2010—Present Florida Board of Medicine
2010—Present Massachusetts Board of Registration in Medicine
IV. AWARDS/HONORS/ACTIVITIES
2013 American Society for Dermatologic Surgery,appointed to Dermatologic Surgery Fellowship
Accreditation Work Group
2013 American Society for Laser Medicine and Surgery,appointed to Strategic Planning Committee and
Marketing and Public Relations Committee
2013 Peer Reviewer,Journal of Cosmetic Dermatology
2012 Peer Reviewer,Lasers in Surgery and Medicine
2011 Guest editor,Seminars in Cutaneous Medicine and Surgery
September 2011,"Cosmeceuticals"
2010 Jaime Battan Compassionate Patient Care Award,in recognition of outstanding resident dedication to
patients
2009 Elected Chief Resident of 22 resident program by faculty
2009 Peer Reviewer,Dermatologic Surgery
JEREMY BLAIR GREEN,MD,FAAD.
2006 Most Outstanding Medical.Student in Dermatology,Miami Miller School of Medicine Dept.of
Dermatology&Cutaneous Surgery
2005 Alpha Omega Alpha(AOA)National Medical Honor Society
2004-2005 Awarded.Honors in University of Miami Clinical Clerkships:General Surgery,Family Medicine,
Obstetrics and Gynecology,Pediatrics,Neurology,Anesthesiology and Dermatology(Mount Sinai,NY)
2003 First.Prize Poster at 4'h Biennial International Society,of Arthroscopy,Knee Surgery,and Orthopaedic
Sports.Medicine 2003,Auckland,NZ
20021003 Northwestern Feinberg School of Medicine Tuition Merit Scholarship
2001 Princeton-University.Department of History,degree Cum Laude
2000 Captain,
.Princeton University Varsity Sprint Football Team
2000 First Team Collegiate Sprint Football League Defensive Back
Second Team(1999).Honorable Mention(1997)
V. SCIENTIFIC AND OTRER PUBLICATIONS
1. Green JB,Fabi S,Kaufman J,Update on lasers for melasma.Dermatology Times,accepted for publication July 2013.
2. -Freedman JR,Greene RM,Green JB,Histologic effects of resurfacing lasers.Facial Plastic Surgery accepted for publication July 2013.
3. Greene RM,Green JB,Skin tightening technologies-.Facial.Plastic Surgery accepted for publication July 2013..
4. Serowka K,Saedi N,Kaufman J,Green JB.Potassium Titanyl Phosphate Laser.Accepted for.publication June 2013,Goldberg D ed.
Lasers and Lights.
5. Green JB,Kaufinan J.Vascular laser research reveals advanced treatment options.Dermatology Times,April 2013.
6. Green JB,Bailin A,Kaufman J.Lasers and lights for acne.Accepted for publication Mar 2013,ZeichnerJ ed..Acrtetform eruptions in
dermatology:a dierentiat diagnosis.
7. Green JB,Kaufman J.Minimizing,marks-Correct combination of laser device with type of acne scar boosts chance of clearance.
Dermatology Times,Jan 2013.
8. Green JB,Kaufman J.Scar insights:laser options continue to grow for hypertrophic,keloid scarring Dermatology Times,Dec 2012.
9. Green JB,Anolik R,Kaufrtian.J.Nonablative fractional lasers afford results,minimize downtime.Dermatology Times.Nov 2012.
10. Saedi N,Green JB,Dover JS,Arndt KA.The Evolution of Quality-Switched Lasers.Journal of Drugs in Dermatology 2012
Nov;11(11):1296-1199.
11. Green JB,Geddes ER,Kaufinan.J.Melanin.measurement tool can increase safety,.efficacy of light=based devices.Dermatology Times.
May 2012.
12. Metelitsa A[,Green JB.Commentary:are all.fractional devices equal with regard to induction of fibrosis? Dermatologic.Surgery 2012
Mar;38(3):443-4..
13. Green JB,Kaufman J.Long-pulsed applications of 1064 nm laser.Dermatology Times.March 2012.
14. Green JB,Kaufman J.Short-pulsed applications°of 1064 nm laser..Dermatology Times.February 2012.
15, Spock C,:Kaufman J,Green JB,et al.Lasers and_light sources to-activatelibroblasts.Cosmetic Dermatology:January 2012;25(1):27-33.
16. Saedi N,Green JB,Kaufman J.Alexandrite laser a versatile tool for a variety of dermatologic applications.Dermatology Times.January
2012.
17. Green JB,Metelitsa Al.Optimizing outcomes of laser.tattoo removal.Skier Therapy Letter.2011;16(10):1-3.
18. Kuzel P,Green JB,Metelitsa Al.Emerging trends And`treatriient approaches in nonmelanoma skin cancer.-a Canadian.perspective.
Journal of Cutaneous Medicine and Surgery.2011 Nov-Dec;15(Suppl 1,):S365-70.
19. Green JB,Kaufman J.Home-use acne�devices,offer expanded options for patients.Dermatology Times.October 2011.
20. Green JB,Kaufman J,Brandt F,et al.Hyaluronic acid.fillers.In Dermatologic Surgery.Step by Step 1st edition,Nouri K ed.Accepted
for publication Nov 2011.
21. Green JB,Kaufman J,Brandt F,et al.Botulinum toxin:orbicularis oris,mentalis,and depressor anguli oris.In Procedures.in Cosmetic
Dermatology 3rd edition,Dover JS ed.Accepted for publication.Oct 2011.
22. Green JB,Metelitsa Al.Introduction to cosmeceuticals..Seminars in Cutaneous Medicine and Surgery.2011 Sept;30(3):139-140..
23. Metelitsa Al,Green JB:Home-use laser and light°skin devices for the skin-an update.Seminars in Cutaneous Medicine and Surgery.
2011 Sept;30(3)'144-147.
24. Green A,Dover JS,Kaminer MS.Tolerability of a monopolar radiofrequency facial skin tightening procedure:An observational study.
Cosmetic Dermatology.July 2011.
25. Green JB,Metelitsa Al,Kaufman J.Intense ultrasound therapy for facial and neck.skin tightening.Dermatology Times:May 2011.
26. Green JB,Kaufman J,Dover J.Short-pulsed laser treatment achieves tattoo removal success.Dermatology Times.December 2010.
27. Green JB,Grunebaum L,Kaufinan.J.Laser,:lighttherapy useful in combating signs of sun exposure on chest,neck.Dermatology Times.
July 2010.
28. Price CJ,Green J,Kirsner RS.Mastocytosis in children is associated with mutations in c-KIT,Journal of 1rrvestigative Dermatology.
2010 Mar 130(3):639.
29. Rico T,Green J,Kirsner RS.Novel antiviral therapy based on innate immunity. Journal of Investigative:Dermatol9gy.1009
Nov;129(t t):2540.
30. Rico TR,Green J.Kirsner RS..Vascular endothelial growth factor delivery via gene therapy for diabetic wounds:.f rst steps.Journal of
Investigative Dermatology.2009 Sep;129(9):2084.
3?1. Green J,Kim N,Kirsner RS.Defining Ro positivity.Journal oflnvestigative Dermatology 2009 Aug;129(8):1848.
32. Romanelli P,Green JB,.Ricotti C,et al.Immunohistochemical evaluation of toxic epidermal necrolysis treated with human intravenous
immunoglobulin.G_ltal Dermaiol Venereol.2008 Aug,143(4):229-33.
33. Halem M,Green J,Kerdel F,et al.Community acquired methicillin resistant Staphylococcus aureus skin infection.Seminars in
Cutaneous Medicine and Surgery.2006;25(2):6&71.
34. Green JB,Lebwohl M.Calcipotriol and.betamethasone dipropionate:a therapeutic combination for psoriasis.Psoriasis Forum.
2006-,.I2(I)A-5.
35. Green J,Roy S.Angiokeratoma.of the Oral Tongue.International Journal of Pediatric Otorhinolaryngology Extra.2006;1(2):107-9.
JEREMY BLAIR GREEN,MD,FAAD
36. Uribe JW,Schurhoff MR,Green:JB,et al.Rotator cuff repair in spinal cord injury patients..Journal of Shoulder and Elbow Surgery.
2003;12(4):327-332.
37. Uribe JW,Schurhoff MR,Green JB.Failure of polymerized-lactic acid tacks in shoulder surgery:JShoulder Elb Surg:2003;12(2):117-
12.1.
38. Green JB..The evolution of Alzheimer's disease:controversies over classification since 1900.Princeton University Senior Thesis,2001.
39. Green JB,Lebwohl M.Interactions of common psoriasis treatments. Psoriasis Forum.Winter 2001.
40. Bethea JR,Green J,Dietrich WD,et al.Systemically administered interleukin-10 reduces tumor necrosis factor-alpha production.and
significantly improves.functional recovery following:traumatic spinal cord injury in rats.Journal of Neurotrauma. 1999;16(10):851-863.
VII.PRESENTATIONS/POSTERS
1. "Laser Update,"Green JB,VII International Dermatologic Galilei Symposium on Psoriasis and Cosmetic Dermatology—University of
Pisa,July 2013,Pisa,ITALY.
2. "High Intensity Focused Ultrasound for Facial Lifting and.Tightening,"Green JB;June 2013,Cali,COLOMBIA.
3. "Laser Update:Vascular and Pigment,"Green JB,Florida Society of Dermatology and Dermatologic Surgery Annual Meeting,May
2013,Boca Raton,Florida
4. "The Aging Face,"Keynote Speaker,Green A,Bioderma Middle East,.6th Annual Rendezvous,May 2013,Savona,ITALY.
5. Green JB,Palomar Medical Technologies Advanced User Symposium,.lectures:and live laser demonstration,April 2013,Boca Raton,
Florida.
6. "Vascular lasers:review and pearls,"Green A Lecture at the American Society for Laser Medicine and Surgery Annual Meeting,April
2013,Boston,Massachusetts.
7. "Experts in the Hall:Starting a Career in Lasers,"Green.JB..Lecture at the American Society for Laser Medicine and Surgery Annual
Meeting,April 2013,Boston,.Massachusetts.
8. Vascular Laser Roundtable,Green JB,Alexiades-Armenakas,Sadick N,VasilyD,Dover JS on behalf of Cutera Lasers,April 2013,
Boston,Massachusetts.
9. "Ultherapy:consistent results from microfocused ultrasound."Green JB.Lecture and live demonstration for Ulthera,March 2013,Miami,
Florida.
10. "New discoveries in,skin rejuvenation and vascular-therapy."Green JB.Orlando.Dermatology Aesthetic and Clinical.Conference,.Podium
presentation/live laseudemonstration for Cutera Lasers,January,2013;Orlando,Florida.
11. "Chemical peels,"Green JB,King P.Grand rounds,University of Miami Department of Otorhinolaryngology,January 3,.2013,Miami,
Florida.
12. "Vascular laser update and advances in body contouring."Green JB.Lecture on behalf of Cutera Lasers,September 2012,Orlando,
Florida.
13. "Vascular laser update and advances in body contouring."Green JB.Lecture on behalf of Cutera Lasers,September 2612,7oronto,
Ontario,CANADA.
14. "Advances in.light-based vascular treatments."Green.JB.Lecture to laser practitioners on behalf of Palomar Medical Technologies,
August 2012,New Orleans,Louisiana.
15. "Latest technology in the treatment of acne&rosacea."Green.JB.,American Academy of Dermatology Summer Meeting,August 2012,
Boston,Massachusetts.
16. "Advanced Aesthetic:Symposium:.Palomar.Icon Platform,,Palomar Acleara Photopneumatic Acne Device,and Palomar MaxG Intense
Pulsed Light for Vascular Applications."Green JB.Lectures to laser practitioners on behalf of Palomar Medical Technologies,June 2012,
Fort Lauderdale,Florida.
17. "A Novel 532nm/1064nm Long-Pulsed Laser,"Green JB.Florida Society of Dermatology and Dermatologic Surgery Annual"Meeting,
May 2012,Orlando,Florida.
18. "Botulinum Toxin My Way, Green JB.Florida Society.of Dermatologyand Dermatologic Surgery Annual.Meeting?May 2012,Orlando,
Florida.
19. "Advanced Aesthetic Symposium:Palomar Icon Platform;Palomar Acleara Photopneumatic Acne Device,and Palomar MaxG Intense
Pulsed Light for Vascular Applications."Green.JB.Lectures to laser practitioners on behalf of Palomar Medical Technologies,May 2012,
New York,New York.
20. "New discoveries in skin rejuvenation and vascular therapy."Green A Lecture to dermatologists and laser practitioners on behalf of
Cutera Lasers,April 2012,Waltham,-Massachusetts.
21. "Real-time melanin measurements to optimize treatment settings and avoid complications."Ross EV,Vasily D,Cohen J,Weiss R,Green.
JB,Kaufman J.Podium presentation at American Society for Laser Medicine.and Surgery Annual Meeting,April 20t2,Orlando,Florida:
22. "New discoveries in skin rejuvenation.and vascular_therapy."Green JB.Lecture,to dermatologists and laser practitioners at American
Academy of Dermatology annual'meeting on,behalf of Cutera.Lasers,March:20121 San Diego,California.
23. "New discoveries in skin rejuvenation and vascular therapy."Green JB.Lecture to local plastic surgeons,dermatologists,and ancillary
staff on behalf of Cutera Lasers,MarO1012.Calgary,Alberta,CANADA.
24. "New discoveries:in skin rejuvenation and vascular therapy."Green JB.Orlando Dermatology,Aesthetic and Clinical Conference,
Podium presentation/live laser demonstration for Cutera Lasers,January 2012,Orlando,Florida.
25. "Vascular lasers:•an update."Green JB..Miami Society for Dermatology&Cutaneous Surgery Meeting,Podium presentation,November
2011,Miami Beach,Florida.
26. "Cosmetic pearls,"Green JB,Brandt FS.Podium,presentation,American Society for Dermatologic Surgery October 2011,Washington
D.C.
27. "Practical cosmeceuticals and pearls for.beginning injectors,"Green JB.Cosmetic Bootcamp University,Podium presentation/live laser
and injectable demonstration,October 201.1,Miami Beach,Florida.
28. "Safety and effectiveness of a high-intensity focused ultrasound device for noninvasive body contouring:a randomized,sham-controlled
study,"Green JB,Dover J,Martin P,et al.Podium presentation,American Society for Laser Medicine and Surgery 2011,Grapevine,
Texas.
JEREMY RLAIR GREEN,MD,FAAD
29: "Correlation of detmoscopic;confocal and histopaihological features of pigmented basal cell carcinoma,"Green JB,Oliviero M,Badiavas
EV,et al.Podium Presentation,Miami Society'for Dermatology and Cutaneous Surgery Resident.Research Symposium 2010,Miami,
Florida.
30. 'Diffuse dermal angiomatosis in the setting ofcalciphylaxis and atherosclerosis,"Green JB,Berman B,Milikowski.C,.et al.Podium
presentation,Gross&Microscopic Section,American Academy of Dermatology 200%.San Francisco,California.
31. "Liquid injectable silicone(Polydimethylsiloxane):Four years of clinical experience,"Green JB,Cazzaniga A,Brandt:F,et al..Poster
presentation,American Academy of Dermatology 2007,Washington D.C.
32. "The role of valgus stress radiography in the evaluation of partial tears of the ulnar collateral.ligament,"Shibayama J,Schorhofl`MR,
Green JB,et-al.Podium presentation,Annual Meeting of the American Orthopaedic Society for Sports Medicine 2002,Dallas,Texas.
VIII.SOCIETY MEMBERSIHPS/LEADERSH.P
• American Academy of Dermatology:Fellow
• American Society for Dermatologic Surgery:.Member,Committee Member
• American Society for Laser Medicine and Surgery-:Member,Committee Member
• Miami Society for Dermatology and Cutaneous Surgery:Member,Treasurer
• Florida Society of Dermatology and.Dermatologic:Surgery:Member
IX.PRESS
Green JB,"Ask the Specialist,"CBS"The Doctors',.air date January 15,2013,discussed laser safety and.1asers for rosacea and in dark
skinned patients.
Green JB,"America's Most Beautiful.Doctors,"CBS:"The Doctors";air date January 8;2013,discussed adult female acne.
Green JB,"No I.Didn't.Get a Face-Lift!"December 2012 Lucky Magazine Beauty Blog by Jennifer Scruby.
http://www.luckymag.conVbeauty/2012/12JNo=I-Didnt-Get-a-Face-Lift
Green JB,"Scars Lcom.Hero:Erasing scars on atl.skin tones:."August 2012.'http://www.scarsl.cbni/Herd/Dr–Je.remy.B_Greell
Green JB,"Everything you need to know about sunscreen this summer,"Interview by Jennifer Scruby for,Health.com also published by
cnn.com and foxnews.com,May 16,2012.
Green JB,."Palomar Medical Technologies Introduces the Skintel Melanin Reader–For Increased:Confidence in Administering Aesthetic
Treatments."Interview by Palomar Medical Technologies for GlobeNewsW,ire press.release,March 13,.2012.
Green JB,"Excel V Treats Full Spectrum of Vascular Conditions;"The Aesthetic Guide,January/February.2012.
Green:JB,"Ask Dr.Brandt,"Guest appearance on Dr.Brandt's Sirius/)(M Stars Network radio show,February 4,2012.
Green JB,"Golden-glow:a doctor's prescription for healthy skin."Horizons Magazine:The Exclusive.Lifestyle Magazine of Royal
Caribbean International."Royal Media Partners,2012 Issue for all Royal Caribbean.Cruise staterooms.
Green JB,"Port Shopping Network(PSN):Cruise vacation sun safety."October 2011,interview playing iwall staterooms on Royal
Caribbean and Celebrity Cruise Lines worldwide.
http://www.youtube.conVwatch?v=yBQIRdU:fcic&list=PL3BECD0234F4F33EB&index=2&feature=plop_video
Green.JB,Dover JS,"Skin cancer:fibur questions Whelp you better understand,"Exha/e Magazine,Summer 2011.
Green JB.Interviewed in Skin and Allergy News by Tucker ME,"High-intensity.focused ultrasound slims waists,study finds."July 2011.
Green JB,Dover JS.``Taking cane of your skin:four common questions answered,"Exhale Magazine,Spring 2011..
X.CLINICAL TRIALSIRESEARCH EXPERIENCE:
201 l—Present Dermatology Research Institute;Coral Gables,FL.Sub-investigator/Principal Investigator;
1. Revance:A phase.3 randomized double-blind parallel-group placebo..-controlled multicenter.study
to evaluate the efficacy and safety of RT001 topical gel for the treatment of moderate.to.severe
lateral canthal lines in.adults(Radiant).
2. Fibrocell: An open-label single center exploratory study to evaluate Azficel-T(LaViv)for
improvement in appearance of fine perioral lines.
3. Allergan:Bimatoprost(Latisse).for the treatment.of eyelash hypotrichosis
4. Cabochon:Data Monitoring Safety Board for Cabochon:Aesthetics'Marquise System'for
improvement in the:appearance of cellulite:
5. Kythera Neck: ATX-101=11-23 Refine 1.&2.Multicenter,randomized,double-blind,placebo-
controlled study:of ATX-101(sodium deoxycholate injection)versus placebo for the reduction of
localized subcutaneous fat in the submental area using magnetic resonance-imaging and a battery of
clinician-and subject-reported measurements:Enrollment initiation.Feb 2012.
JEREMY BLAIR GREEN,MD,FAA ID
6. Medicis Restylane Lip:MA-1700-04 A randomized,evaluator-blinded,no-treatment control study
of the effectiveness and safety of small particle hyaluronic acid plus lidocaine(SPHAL)in the
augmentation of soft.tissue fullness of the lips.
7. Medicis Perlane Mid-Face:MA-1400-05 A randomized,evaluator-blinded,no-treatment-
controlled study of the effectiveness and safety of Perlane-L in the.correction of midface volume
deficit and/or midface contour deficiency.Enrollment initiation Mar 2012.
8. Palomar Medical:Palomar Icon Skintel Validation.Beta testing of:company's proprietary
melanin-measuring technology to determine appropriate,intense pulsed tight settings-20,
,m
9. Allergan:.Aulticenter,double.blind,:placebo controlled study assessing.patient satisfaction with
.Latisse®(Bimatoprost Ophthalmic Solution 0.03%)for increasing eyelash prominence.2011.
10. Noven Pharmaceuticals:A randomized,double blind;parallel group,multicenter,placebo
controlled study of the.safety and efficacy of HTU-520 in the treatment of mild to moderate distal
subungual onychomycosis of the.tociWls.2011.
.2010-2011 SkinCare.Physicians,Chestnut Hill,MA.Sub-investigator:
1) Cabochon:Pilot study of Cabochon Aesthetics'.Marquise System for improvement in the
appearance ofcellulite,CP-0 1-1003.Trial end date:12/10.
2) Zeltiq Abdomen:Non-invasive reduction of abdominal.fat utilizing the Juno applicator,ZA10-
001.Trial end date: 10/10. -
3) Kythera Neck:Multicenter,randomized,double-blind,placebo-controlled study of ATX-101
(sodium deoxycholate injection)versus placebo for the reduction of localized subcutaneous fat in
the submental area..using'magnetic resonance imaging and a battery of clinician-and subject
reported measurements,ATX-101-09-15.Trial_end date:11/10.
4) 732 Reloxin;A Phase 3,Multicenter,Open-Label Extension Study to Assess the Long-Term Safety of
Administrations of Reloxin in the Treatment ofGlabellar Lines.Trial.end_date.'12/10.
5) Allergan: JULIDO-002.Juvederm Ultra XL injectable gel for lip,augmentation.Trial end.date:
08/11.
6) Medicls:A PhaseJV,open label study.evaluating themse of.Solodyn,:Ziana,and Triaz foaming
clothes as combination acne therapyAs an alternative to treatment with isotretinoin.Trial end date:
11/11.
7) Allergan:Multicenterdouble blind randomized placebo-controlled parallel group study to evaluate
the safety and efficacy of Botox purified neurotoxin in patients with facial rhytides,crow's feet
lines and glabellar lines.Trial end date:08111.
8) Sound Surgical Technologies:Protocol to evaluate patient measurements after ultrasonic
treatment of back fat.
9) Palomar Medical:Pilot study of laser treatment of actinic keratosis.Trial duration:3 months.
10) Cynosure:Protocol CYN09-PiCO-ll Clinical evaluation of picolase 755nm alexandrite laser for
treatment of unwanted tattoos.Start date:2/23/11.
1) Kythera:5-year extension of ATX-101708712.Long-term follow-up"study of subjects who
completed Kythera-sponsored trials of ATX-101(sodium deoxycholate injections)for the reduction
of localized subcutaneous fat in the submental.'area.
12) Bella Contour:BELLA01 pilot study to confirm logistics of United States pivotal Bella Contour
study.Start date`:VIVO
2005 Universityof Miami Microsurgical Training Center,Miami,FL
Completed 22-hour vascular surgery course supervised by neurological surgeon Dr.Edir Siquera..
2001-2002 UHZ Sports Medicine Institute;.University of Miami,FL
Full-time research;fellow performing clinical outcome.studies.
1997-1998 Miami Project to Cure Paralysis,Miami,FL
Summer research assistant to.Drs.Alexander Marcillo and.John Bethea:Examined various neuro-
protective agents'utilizing'a mouse spinal cord injury model.
X1.COMMUNITY/EXTRACURRICULAR
2011—Present Princeton in Dermatology,Co-Founder
2007-Present Skin:Canccr.Screening Volunteer,Ikliami,FL, Key West,FL
Sylvester Cancer Center Deerfield,.Women's Dermatologic Society,Florida.Keys Health Fair,Sunsmart
Sprint 5K for Melanoma Awareness(bronze medalist in age group 2008,2009,and 2010):
2000-Present Project Medishare:for Haiti,Miami,FL and Haiti
Fivearips;to Port au Prince and the central plateau on medical missions with University of.Miami
medical students and physicians.Involved in post-January 2010 earthquake fundraising and medical
relief efforts.All aspects of care especially tropical dermatology:
2004-Present Princeton Clubs of South.Florida/New'England,Miami,,FL,Boston,MA
Alumni interviewer for area high school student applicants.
2007-2010 Camillus House,Miami,FL
Volunteer at homeless shelter staffing Dermatology clinic.
2004-2006 University of Miami Clinical Skills Educator,Miami,FL
Certified trainer for 0/2nd year medical students in physical exam.
2002-2004 Northwestern:University Student Senate,Chicago,IL
JEREMY BLAIR GREEN9 MD,FAAD
Twice elected Student Senator by'Class of 20.06.Organized fundraisers;class.events,and attended
monthly meetings with deans.Elected to Executive Board.byStudent Senate;Student,Organizations
Chairman.Allocated-funds:to 30 student groups..
2002—2004 Loyal Davis Surgical Society;.Chicago,,IL.
Co-President.Organized presentations by Northwestem.faculty.
2002—2004 Ashland'Clinic,Northwestern,Chicago,IL
Clinic translator for underserved Spanish-speakin&pppulation.
1997—2001 YWCA English as a Second Language Program,Princeton,NJ
Tutored Latin American immigrants in conversational English.
1997—2001 Princeton University Varsity Sprint Football,Princeton;NJ
2000 Captain of 40-person team.4-year Letter winner.
1999—2001 Tiger Inn Eating Club,:Princeton,NJ
Founded English as a Second Language program'to tutor University dining hall staff.Efforts featured.in
front page Daily Princetonian article.Elected Officer,member Princeton Inter-Club Council for 150-
member club.
XII. GOOD CLINICAL PRACTICE TRAINING
10/26/2010-Dermatology Research.Institute SOP 5000 based on National Institute of Health(NTH)Clinical Research Training and
educational standard issue by the NTH for conducting clinical research.
07/28720.11-NTH web-based training course,"Protecting Human Research Participants:"Certification Number:;722082
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Mr®°�'DE SOURCE OF INCOME STATEMENT
a
Disclosure for Tax Year Ending Last Name First Name Middle Name/Initial
-3 62-9 cc/v .
Mailing Address—Street Number,Street Name,or P.O.Box
City,State,Zip ID Number
If your home address is your mailing address,and your home address is exempt from public records pursuant to Fla.Stat.§119.07,read
instructions on the following page and check here.❑
Filing as an Employee
❑County Employee ❑Municipal Employee, Name of Municipality:
Position held or sought
Department where employed
Work address Work telephone Term began on
Filing as a Board Member
F] CountyBoard Member Municipal Board Member, Name of Municipality:
A
Board where serving / ,,11 r
Work address Work telephone Term began on
List below every source of income you received,along with the address and the principal activity of each source.Include your public salary.Place
the sources of income in descending order, with the largest source first.Also, include any source of income received by another person for your
benefit. However,the income of your spouse or any business partner need not be disclosed. If continued on a separate sheet,check here.❑
Name of Source of Income Address Description of the Principal Business Activity
A*N (Ate, L6 6,
coaA 6A/,U. Fc— 331 "It
I hereby swear(or affirm)that the information above is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT. _
❑ Hardcopy
❑ Electronic Copy
gnature of n disclosing
Print name Date signed
OFFICE USE ONLY Accepted: Y / N Deficiency: °rocessed Date'Initia!s: Scanned Cu=te/Initials:
138 SP-i" 2/13
MIAMI BEAC
City of Miami Beach,
1700 Convention Center Drive,
Miami Beach,Florida 33139,
www.miomiheochfl.aov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel:305.673.741 1 ,Fax:305.673.7254 .
Acknowledgement of fines/suspension for Board Members for failure
to comply with Miami-Dade County Financial Disclosure Code Provision
Code Section 2-1 1.1(i) (2)
Board Member name: .
understand that no later than JULY 1 OF EACH YEAR all members of Boards and
Committees of the City of Miami Beach, including those of a purely advisory nature, are
required to complywith Miami-Dade County Disclosure Requirements. This means thatthe
members of City Advisory Boards, whose sole or primary responsibility is to recommend
legislation or give advice to the City Commission,-must file,even though you may have been
recently appointed.
You must file one of the following with the City Clerk of Miami Beach, 1700
Convention Center Drive, Miami Beach, Florida, by July 1, 2010.
1. A`'Source of Income Statement (attached) or
2. A'`Financial Statement(attached( or]
3. A Copy of the person's current Federal Income Tax Return
Failure to file, according to the Miami-Dade County Code Chapter 1, General
Provision, Section 1-5 may subject the person or firm to a fine not to exceed
$500.00 or by imprisonment in the county jail for a period not to exceed sixty
days, or both.
atur Date:
MIAMI
City of Miami Beach
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miam ibeachfl:gov
CITY CLERK'S OFFICE CityClerk @miamibeachfl.gov
Telephone: 305.673.7411 Fax: 305.673.7254
Acknowledgement of fines/suspension for Board/Committee Members for failure to comply with Mlami-
Dade County Financial Disclosure,Code.Provision.Code.Section 2-11.1(1)(2)
m ���
Board Member's Name:b _
Understand that no later than July 1,.of each year all members of Boards and Committees. of the City of
Miami Beach, including those of a purely advisory nature, are required to comply with Miami-Dade County
Financial. Disclosure Requirements. This means that the :members of City Advisory Boards, whose sole or
primary responsibility is to recommend legislation. or give advice 'to the City Commission, must file, even
though-they may have been recently appointed.
One of the following forms must be filed with the City Clerk of Miami'Beach, 1700 Convention Center Drive,
Miami Beach, Florida, no later than 12:00 noon of July 'i, of each year.
1. A"Source of Income Statement"
For your convenience,the form is attached. The form can also be,downloaded.at:
http://.www miamidade gov/elections/Library/source of income statement.odf
2. A"Statement of Financial Interests.(Form 11)"
For your convenience.,:the-form is attached. The form can.also be downloaded.at:
hftp://.wwW.ethits.state.fl.us/othics/forms.htmI
3. A Copy of your 2013 Federal Income Tax Return
Failure to file one of these forms, pursuant to the Miami-Dade County Code, may subject the person to at fine
of no more than$500, 60 days in jail or both.
Signature Date
Updated:Monday,December 16,2013
Page 4 oft
F:ICLERI$ALL\aFORMSIBOARD AND COMMITTEESIBC APPLICATION 46 BOARDS 12-16=2013.doc
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