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Get WI WKC-16-B 2010

Ted and whether stump is tender or hardy. 17. What is the prognosis of this disability? If guarded, please explain: 18. Do you expect that any further treatment will be necessary for this condition? Yes No If YES, explain: 19. Prior to this accident or illness, did employee have any permanent disability? Yes No If YES, explain: 20. I am a practitioner licensed in and practicing in Wisconsin. Practitioner Typed or Printed Name: Practitioner Address (Street or P.O. Box): Practitioner Addr.

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