Austin Fitzgerald

 
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 TOWER PHYSICAL THERAPY, INC. 
 patient: Austin Fitzgerald
 Address 700 FLOWER ST 
 City TURLOCK Zip Code 95780 
 Birthdate November 23, 2002 
 Social Security Number 557-57-0573 
 Sex: M F 
 Primary Phone (257)571-3570 
 Email: (for appointment reminders) EF5767@LIVE.COM 
 Employer SUNNYSIDE FARMS DAIRY 
 Occupation PACKAGING OPERATOR 
 Work Phone: 657-3577 
 Emergency Contact CINDY FOSTER 
 Phone (257)257-5574 Relation SPOUSE 
 ASSIGNMENT OF BENEFITS 
 Authorization for treatment is hereby given to Tower Physical Therapy, Inc. I assign them all payments for 
 medical services rendered. 
 X Ed Foster 
 January 19, 2022 
 Patient or Guardian Signature 
 Today's Date 
 CONTINUE ON BACK 
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