HomeMy WebLinkAboutMedical Release - Sherri Bellard ivivircuia ia:ou (FAX) P.0011001
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MEDICAL CLEARANCE REQUEST
Date : it t 1) 1 c
Patient: 61ht {X I be O i GI
Diagnosis: UM/A `-fie -./7(Wl1(0f
Procedure: 1.1.4kAt a ( -Ibt 0- f 'e 0 I 0 (''.-' 4-H(0 (
i--5 I 1
Date of Servat 1'05 W
CLEARED:
TO INCLUDE: STRESS TEST
ECHOCARDIOGRAM
EKG
CHEM. PANEL
CBC W/DIPS.&PLATELETS
PLEASE PRINT PHYSICIAN NAME & PHONE NUMBER:
PHYSICIAN SIGNATURE:
,r'- 016 z,Q7—.2___
Please fax to 713 984 0544
Jack E Jensen MD Mark Geyer MD
Don Baxter MD _.....R.Alexander Mohr MD -
E.Sadeghpour MD Pawan Grover MD
9180 KATY FREEWAY* STE 200* HOUSTON,TX 77055 PH:713 9841400 FAX 713 984 0544