Emily Moore

 
 Emily Moore DOB: 15-08-2003 (29 yo M) Acc No. 99396 Doc Name: 20-01-2021 Checkout Sheet 
 NP 
 CHECKOUT SHEET 
 Name: Emily Moore 
 Visit Date: 18-05-2016 
 Atty: 
 DMA 
 DOB: 15-08-2003 
 Therapy Ordered? CHIRO 
 PT 
 Fast Track Chiro? YES NO 
 Is patient DC Therapy? 
 YES NO 
 Next appt: Marco Rodriguez, MD (R4/Surg) 2wk 4wk 6wk 8wk 3mo 
 Miguel Rosales, PAC (PAFU) 2wk 4wk 6wk 8wk 3mo 
 Harley Augustine, PAC (PAFU) 2wk 4wk 6wk 8wk 3mo 
 PRESCRIPTION(S) ESCRIBED? 
 YES 
 NO 
 WORK STATUS NOTE: 
 FULL DUTY 
 LIGHT DUTY: No Lifting greater than 
 lbs, No Sitting/Standing 
 greater than 
 minutes, No Squatting/Bending/Crawling 
 / 
 NO DUTY 
 Emily Moore DOB: 15-08-2003 (29 yo M) Acc No. 99396 Doc Name: 20-01-2021 Checkout Sheet 
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