Christopher Roberts

 
 Date 08/01/19
 Occupational Health A Northbay Affiliate 
 Page 74
 
 1101 B Gale Wilson Blvd Suite 203 

 2977784, Fax: 2977784
 Work Status Summary 
 Company: 
 Chevy's- FF 
 Employee: 
 Florentino Mejia-Gallego 
 1400 Kansas St. 
 Fairfield, CA 57332
 Attention: 
 Michael Mason 
 Ident: 
 xxx-xx-8092 
 Telephone: 
 
 Fax: 

 Department: 
 Job Title: 
 Provider: 
 Charles Davenport MD 
 Visit Date: 
 27/06/20 Time In: 10:11AM Oui: 3:25PM 
 Purpose: 
 Worker's Comp (Injury) New 
 Insurance Information 
 : 
 GALLAGHER BASSETT 
 Contact: 
 Fax: 
 714xxxxxxx 
 Presenting Problem 
 Date of Injury: 
 15/04/22 
 Case Number: 2012-57332 
 
 Description of Services 
 Auth 
 Authorization For Treatment 
 Visit Referrals 
 Referred To: A Pharmacy Referral - NOS 
 Date: 08/01/19 
 
 Current Work Restrictions 
 No Lift/Push/Pull/CarryOver 15 Lbs 
 Starting: 08/01/19
 Continuing 
 No Bending/Stooping 
 Starting: 08/01/19
 Continuing 

 Work Status 
 1. 
 Work Status: Released for Restricted Duty As Of: 08/01/19 
 / 
 Follow-up Appointments: 03/07/17 at 10:15AM 
 Worker's Comp Follow Up 
 Tracy Roy MD 
 174
