Va Form 10-10m - Medical Certificate Page 3

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SECTION II - FOR PATIENT
1. DISPOSITION/CLINIC APPOINTMENT
2. AFTER CARE SHEET GIVEN
3. FOLLOW UP-ACTIVITY-LIMITATIONS
YES
NO
4. CONDITION
5. DATE/TIME OF DISCHARGE
6. SIGNATURE TO INDICATE INSTRUCTIONS GIVEN
IMPROVED
SATISFACTORY
UNCHANGED
7. PATIENT INSTRUCTIONS
IMPRINT PATIENT DATA CARD
I CERTIFY THAT I RECEIVED AND
8. PATIENT’S SIGNATURE
UNDERSTAND THESE INSTRUCTIONS
VA FORM
10-10M
PATIENTS COPY
PAGE 3
MAR 1992

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