Kelsey Ruiz

 
 Patient 
 seeds this form filled 
 US. Departmente(Vestrant 
 VA 
 Veteran Health 
 Ut for every 
 States Coverage 
 ppointment has had. Southeast Louisiana Veteran Health 
 Care System 
 2466 Canal Street 
 New Orleans, LA 70166 
 Facility Name: Louisiana pain Specialists 
 Address of Facility: 5600 Read Blvd 10th flower, N.O, (A 70166 
 Phone number of Facility: 
 504. TEA 2366
 Time of appointment: 
 9:40 Am 
 Date of appointment(s): 
 08-10-2021
 Veteran's Name 
 Kimberly Luna
 Veteran last four (SSN): 37166 
 I certify that the veteran named above attended said appointment as per Department of Veteran Affairs. 
 Signature: Spaymeno 
 Date: 06-12-2023
