Zoe Washington

 
 <<Back to Review>>180298-26-HYPERLINK- Hyperlink-Page 
 205 
 Work Wellness 
 July 25, 2018 
 1431 Colorado Ave Ste 143 Turlock, CA 94382 
 Page 1 
 (243) 243-3433 Fax: (439) 436-3430 
 Patient Information 
 For : Zoe Washington
 Work Status Report 
 Date of Report: Jul 28, 2015
 Time In: 1:5 AM 
 Time Out: 10:06 AM 
 Date of Injury: Jun 14, 2018 
 Diagnosis: 
 Cholecystitis (ICD-719.47) (ICD10-M25.571)  
 Pursuant to California Civil Code section 53.31 and Labor Code 3762. medical information regarding employee'92 worker'92 compensation injuries is 
 deemed confidential medical information and may not be disclosed except in very limited circumstances.
 Instructions: - seated work only 
 Electronically signed by: Jennifer S Wong DO (Nov 09, 2022) 
 Patient Signature: 
 Ed Foster 
 Date: Sep 11, 2020 
 004305 
 pr tae 0435
