Jack Barrett

 
 26/14/11 19:59:15 EDT 
 To: 19512226812 
 Page: 05/612 
 From: Lauris Rigdon 
 Fax: 3124912212 
 Signatures 
 Treating Provider Signature 
 Initiated by Maria Stalder, PT, DPT on 02/15/04 14:56 EDT. License #: 049147 
 Electronically co-signed by Mary Smith, PT on 27/15/12 16:01 EDT. License #: 024128 
 Patient Shauna Becker (DOB: 03/02/07) 
 Treated by Maria Stalder, PT, DPT (License #129112) 
 DOS: 03/23/09
 Page 4 of 12 of Plan of Care
