Jordan Walters

 
 Jordan Walters DOB: 01/2004/13 (15 yo M) Acc No. 77618 Doc Name: 09/2019/14 Inj 
 3 
 Room: 7 
 Pain: 
 Ht 518 
 CONSENT TO MEDICAL OR SURGICAL 
 LA HEALTH SOLUTIONS (504)262-8889 
 Wt: 248 
 3001 DIVISION STREET, STE104 
 606COLONAL DR,STE A 
 PROCEDURES, OPERATIONS, & 
 METAIRE, LA 70002 
 BATONROUGE LA70806 
 RONALD SEGURA M.D. 
 RICHARD ROBERTSON, M.D. 
 MEDICAL SERVICES 
 hereby authorize and direct Dr. Ronald Segura, and/or.Dr. Richard Robertson, with associates and 
 assistants of his choice, to perform upon: 
 Jordan Walters 
 01/2004/13, 38175, male 
 Cervical tacet 
 he following medical diagnostic and /or therapeutic procedure or surgical operation: 
 Right C5l6 C6/7 C7/T, 
 hereby certify that I understand this consent and that all questions about the procedure / 
 procedures have been answered in a satisfactory manner and that all blanks were filled in prior to 
 my signature. 
 Date: 09/2023/09 20 
 Time: 7:15 
 a.m / p.m. 
 Signature of Patient: 
 Signature of Relative 
 Witness: I 
 | cerify that all blanks in this form were filled in prior to signature and that I expl ained them to the 
 patient or patient representative before requesting the signature. 
 I 
 RS 
 Ronald Segura, M.D. 
 Richard Robertson, M.D. 
 Jordan Walters DOB: 01/2004/13 (15 yo M) Acc No. 77618 Doc Name: 09/2019/14 Inj 
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