NAME, ADDRESS AND TELEPHONE NUMBER OF DOCTOR YOU ARE CURRENTLY TREATING WITH:

HOW OFTEN ARE YOU RECEIVING PHYSICAL THERAPY?

ARE YOU TREATING WITH ANY SPECIALIST?

IF SO, LIST NAME, ADDRESS AND TELEPHONE NUMBER OF SPECIALIST:

PRESENT COMPLAINTS:

DO YOU HAVE ANY TINGLING, NUMBNESS OR FALLING ASLEEP SENSATIONS IN YOUR ARMS OR LEGS?

ARE YOU SATISFIED WITH THE TREATMENT YOU ARE RECEIVING FROM YOUR DOCTOR?

HAVE YOU COMPLETED YOUR TREATMENT?

IF SO, WHEN WHERE YOU FORMALLY DISCHARGED?

DID YOU MISS TIME FROM WORK?

IF SO, LIST DATES YOU MISSED FROM WORK

Leave this empty:

Your legal name

Please Confirm full name and signature.

Change fonts

• Draw Signature
  
• Type In Signature
  

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

Insert Signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signature Certificate

Document name: Treatment Status - Jeanette Keller

Unique Document ID: 18d3482c739b23bf448eb0dc46d193caf2064ffb

Build. Track. Sign Contracts.

Timestamp	Audit
June 30, 2020 6:21 pm GMT	Treatment Status - Jeanette Keller Uploaded by David Rosenbaum - test@rosenbaumfirm.com IP 162.221.24.2
June 30, 2020 6:22 pm GMT	Jeanette Keller - jkeller@rosenbaumfirm.com added by David Rosenbaum - test@rosenbaumfirm.com as a CC'd Recipient Ip: 162.221.24.2

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://www.rosenbauminjuryfirm.com/

Audit Trail Serial# 78d6c7fb8d267494b06be0df1bcd121b