Adam White

 
 OCCUPATIONAL HEALTH 
 A NorthBay Affiliate 
 1301 B. Gale Wilson Blvd., Suite 203, Fairfield, CA 93033 (730) 306-4300 
 (X) INDUSTRIAL INJURY 
 DRUG NAME 
 Mg or CC 
 Signature 
 No. 
 Refill 
 1. 
 2. 
 3. 
 M.D. 
 Patient 
 Lic. # 
 DeA# 
 M.D. 
 Address 
 Date 
 Detach Prescription Here 
 Employee : 
 Employer 
 injury date
 06-17-2014 
 IMPRESSION: 
 Visiting Date 12-20-2019  
 Time In 
 ( ) First Aid Care 
 ( 
 ) Condition judged non-work related 
 ) Causation unclear 
 Time Out 
 9:1 
 DISPOSITION AND INSTRUCTIONS 
 I acknowledge l'hav猫 received and understand these instructions/r 
 RETURN TO WORK AUTHORIZATION 
 3014 (3302) 
 Top - White 2nd - Yellow
