Physical Education School

Note to patient:

x Was evaluated by me on: */**/*2.

Was seen in my office on: x May return to work/school on: 7/19/22.

May not return to work/school on: Work limitations: May not participate in physical education: May return to physical education: Limitations for physical education: May not participate in jury duty: Sincerely,

Electronically Signed by: MARGARITA RICE, NP

Affiliated Physicians Group • 93 Pond Street, SHARON MA 02067-2015 SMITH, Deborah A (id #252094, dob: 03/21/1952)

Beth Israel Deaconess HealthCare

93 Pond Street

SHARON, MA 02067-2015

Phone: 781-***-****

Fax: 781-***-****

Return to Work / School

Patient: Smith, Deborah A Date: 07/18/2022

DOB: 03/21/1952 Patient ID: 252094

Address: 50 Churchill St

Milton, MA 02186-1440

Affiliated Physicians Group Smith, Deborah A (ID: 252094), DOB: 03/21/1952