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PRIMARY TREATING PHYSICIAN'S PROGRESS REPORT (PR …
Primary Treating Physician: (original signature, do not stamp) Date of Exam. I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated . Labor Code section 139.3. Physician signature . Cal. License Number: Executed at: Date (mm/dd/yyyy): Physician Name . Specialty: Physician ...
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