John Romero

 
 October 12, 2017 19:59:15 EDT 
 To: 19531226831 
 Page: 05/631 
 From: Lauris Rigdon 
 Fax: 3314931231 
 Signatures 
 Treating Provider Signature 
 Initiated by Maria Stalder, PT, DPT on April 19, 2022 14:56 EDT. License #: 049147 
 Electronically co-signed by Mary Smith, PT on August 13, 2021 16:01 EDT. License #: 024318 
 Patient Shauna Becker (DOB: July 22, 1999) 
 Treated by Maria Stalder, PT, DPT (License #319131) 
 DOS: September 06, 2017
 Page 4 of 31 of Plan of Care
