Rachel Perkins

 
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 23 
 TRI VALLEY ORTHOPEDIC . 4626 Willow Road, PLEASANTON CA 94458-8454 
 Rachel Perkins (id #345145, birth date: 10/2000/14) 
 List each specific requested medical services, good, or items in the below space or indicate the specific page numper(s) 
 of the attached medical report on which the requested treatment can be found. Up to five (5) procedures may be entered: 
 Diagnosis (Required) 
 ICD-Code (Required) 
 1. Closed bimalleolar fracture - Right 
 S82.841P: Displaced bimalleolar fracture of right lower leg, subsequent 
 encounter for closed fracture with malunion 
 Service/Good Requested (required) 
 Right ankle ultra guidance cortisone injection 
 Requesting Physician Signature:signature: SEAN DOUGHERTY, DPM 
 Date:04/2017/20
 Sean Dougherty DPM 
 000023 
 0023
