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WHAT WE TREAT
About Dr. Avery
Our Services
Why No Insurance?
Contact
Our Programs
Diet Terminator
INFUZN: CHRONIC PAIN PROGRAM FORM
3 Tips Low Back Pain/Sciatica
Other Programs
Resources
Testimonials
Book Now
Home
WHAT WE TREAT
About Dr. Avery
Our Services
Why No Insurance?
Contact
Our Programs
Diet Terminator
INFUZN: CHRONIC PAIN PROGRAM FORM
3 Tips Low Back Pain/Sciatica
Other Programs
Resources
Testimonials
Book Now
Patient Name
First Name
Last Name
Work Event
Date Month
MM
01
02
03
04
05
06
07
08
09
10
11
12
Date Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Date Year
2018
2019
2020
Time In Hour
09
10
11
12
01
02
03
04
05
06
07
08
Time in Minutes
00 a.m.
05 a.m.
10 a.m.
15 a.m.
20 a.m.
25 a.m.
30 a.m.
35 a.m.
40 a.m.
45 a.m.
50 a.m.
55 a.m.
00 p.m.
05 p.m.
10 p.m.
15 p.m.
20 p.m.
25 p.m.
30 p.m.
35 p.m.
40 p.m.
45 p.m.
50 p.m.
55 p.m.
Time Out Hour
09
10
11
12
01
02
03
04
05
06
07
08
Time Out Minutes
00 a.m.
05 a.m.
10 a.m.
15 a.m.
20 a.m.
25 a.m.
30 a.m.
35 a.m.
40 a.m.
45 a.m.
50 a.m.
55 a.m.
00 p.m.
05 p.m.
10 p.m.
15 p.m.
20 p.m.
25 p.m.
30 p.m.
35 p.m.
40 p.m.
45 p.m.
50 p.m.
55 p.m.
Subjective
Objective
Assessment
Plan
Electronic Signiture
Dr. Eric Avery, PT, DPT, CO PTL 0008633
Start Mileage
End Mileage
Thank you!
