PROPOSITION 115 FOR MEDICAL STAFF DR#:(Required) Date MM slash DD slash YYYY Physician/Physician Assistant Name(Required) Email(Required) REFUSED TO PROVIDE INFORMATION BELOW REFUSED TO PROVIDE INFORMATION BELOW Patient Medical ConditionWERE THESE INJURIES AND TREATMENTS RECORDED IN THE MEDICAL RECORDS?IN REGARDS TO THE FOLLOWING PATIENT(S), WHAT INJURIES WERE SUSTAINED?EducationUndergrad UNDERGRAD School Name: Date Graduated Month Day Year MEDICAL/PHYSICIAN ASSISTANT SCHOOL MEDICAL / PHYSICIAN ASSISTANT SCHOOL School Name: Date Graduated Month Day Year GENERAL SURGERY RESIDENCY GENERAL SURGERY RESIDENCY School Name: TRAUMA SURGICAL FELLOWSHIP IN CRITICAL CARE TRAUMA SURGICAL FELLOWSHIP IN CRITICAL CARE School Name: Employer: CERTIFICATIONSCA STATE MEDICAL LICENSE CA STATE MEDICAL LICENSE Year Issued: BOARD CERTIFIED BOARD CERTIFIED Type(s)I HAVE VERBALLY CONFIRMED THE INFORMATION PROVIDED ON THIS DOCUMENT.OFFICER NAME(Required) BADGE# DATE MM slash DD slash YYYY Enter an email address to send a copy of this completed form to:(Required)