Eduardo Harris

 
 O 
 onecallo care 
 PHYSICAL THERAPY 
 FAX / EMAIL Confidential - 8/7/2018 7:38:15 PM 
 PATIENT REFERRAL FORM 
 Referral Date: Jun 24, 2022 
 Claim Number: PZC17921734 
 Patient Data 
 Name: Eduardo Harris
 Sex: Male 
 BIRTHDATE: Aug 25, 2003 
 injury date: Oct 14, 2022 
 Injury State: CA 
 Injury: MULTIPLE PARTS 
 Injury: Other, please see details. 
 Body Part Side: Right 
 Details: right ankle and joints ofright foot 
 Injury Is Surgical: U 
 Physician Info 
 Physician: Jenny Wong 
 Next MD Appt: 8/8/2018 
 ***DO NOT ISSUE DME/Home E-stim without prior authorization from One Call Physical Therapy* 
 All DME requests must be pre-authorized. Please submit written MD orders to One Call Physical Therapy. 
 (AG:12-EMBID-1753174: 
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