Form Pr-3 - Primary Treating Physician'S Permanent And Stationary Report Page 8
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8STATE OF CALIFORNIA
Division of Workers’ Compensation
PRIMARY TREATING PHYSICIAN’S PERMANENT AND STATIONARY REPORT (PR-3)
Primary Treating Physician (original signature, do not stamp)
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 §139.3.
Signature:
Cal. Lic. # :
Executed at:
Date:
(County and State)
Name (Printed):
Specialty:
Address:____________________________________City:___________________State:______Zip:
Telephone:______________________________________
DWC Form PR-3 (Rev. 01/01/05)
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