First aid only




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tarix15.04.2016
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WORK STATUS

Name: Employer:

Date: Contact:

Claim #: Case #: Phone:

Occupation: Visit authorized by:

Time in: Time Out: Fax:





  • This is a work related injury.

  • This is not a work related injury

  • RTW without restrictions ________

  • Off work to __________

  • Permanent & Stationary

without restrictions, no future medical

RTW on_______________________ with the following restrictions:









Diagnosis
TREATMENT ADMINISTERED:

  • Office Visit/injury Treatment

  • Medication: ________________________________

  • Referral To: ________________________________

  • Resumption of duties to be determined by specialist

  • Physical Therapy. Times per week

  • Supplies Dispensed: ______________________

Specialty: _________________________________




PATIENT STATUS:

I do expect that the patient will return to regular work on _________________________

Estimated length of treatment _______________________________

Since the last exam, the patient's condition has:


  • Improved as expected

  • Worsened

  • Improved, but slower than expected.

  • Permanent and stationary with above restrictions

  • Not improved significantly.

  • Report to follow

Briefly describe any change in objective or subjective complaint: ___________________________________




YOUR NEXT M.D. APPOINTMENT IS:

_ MON. _ TUES. _ WED. _ THURS. _ FRI. _ SAT. You have been discharged from Medical Care __

DATE: ______________________ TIME: ____________ BeforelAfter Shift

PLEASE TELEPHONE IN ADVANCE IF YOU WILL BE UNABLE TO KEEP THE APPOINTMENT


I hereby acknowledge receipt of the instructions indicated above



___________________________________________________ ____________________________________________

Patient/representative signature Date Physician Signature Date
THE WORK PLACE

Simi Valley Hospital & Health Care Services Jonathan Miller, M.D. Date

2975 N. SYCAMORE Dr

SIMI VALLEY, CA 93065 MD

(805} 583~3200 FAX (805) 579-6186



AFIM 7609 1097 White - Patient Yellow - Employer Pink - Medical Record


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