Employers Efroi Worksheet Page 4

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Medical treatment
*Did the employee already receive treatment of this injury Yes____ No____ Unknown____
*If yes what was the date of the employee’s first treatment___________
*Extent of medical treatment received by claimant immediately following the accident:
Doctors’ office____ Hospital____ Emergency Room____
*Who treated the employee? ____________________________________________________________
*Where was the employee treated?_______________________________________________________
*Is the employee still being treated for this injury Yes____ No____ Unknown____
If yes, where?(Name & Address) ___________________________________________________
Please provide any additional info_________________________________________________________
____________________________________________________________________________________
*I affirm that the info I am providing is true and accurate Yes____
Name & Telephone Number of Person who provided information Necessary to prepare this form
*First Name _________________________________
*Last Name__________________________________
*Telephone Number___________________________

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