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