John Smith, MD

Family and General Medicine

1600 Creekside Dr., Suite 3300

Folsom, CA 95630

voice (916) 984-0000

fax (916) 983-0000

HealthSouth Physical Therapy

1611 Creekside Dr., Suite 100

(across the stree from Mercy Folsom Hospital)

Folsom, CA 95630

(916) 984-7909, fax (916) 984-7919

This is a request for Physical Therapy

James, Patricia dob 02/01/1926 76 & 3/12 y/o 4/9/02

941-0000 ---

PT please for R shoulder myalgia x 6 weeks

Thank you,

Electronic signature John Smith, MD

John Smith, MD