John Smith, MD
Family and General Medicine
1600 Creekside Dr., Suite 3300
Folsom, CA 95630
voice (916) 984-0000
fax (916) 983-0000
Radiological Associates
1561 Creekside
Dr.,(immediate left after entering bldg)
Folsom, CA 95630
(916) 984-0739
This is a request for x-ray service for
James, Patricia dob 02/01/1926 76
& 3/12 y/o 4/9/02
000-0000 000-0000
screening mammogram
Thank you,
Electronic signature John Smith, MD
John Smith, MD