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Rodrigo Jimenez

CREFITO 122314

Cascavel, ______ de ____________________ de 20____.


Declaro

para

os

devidos

fins

que

(a)

Sr(a)___________________________________________, sofreu um acidente de trnsito


na

data

de

_______/_______/_______sendo

atendido

(a)no________

_____________________________________________________________________________________
__,
apresentando_____________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________
Sendo

realizado

tratamento______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
____
O (A) periciado(a) segue com limitaes e redues funcionais (Dor,
FM, ADM):___________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Rua General Osrio, n 2567, Ciro Nardi, Cascavel - PR

Rodrigo Jimenez
CREFITO 122314

_____________________________________________________________________________________
______________________
__________________________
Rodrigo Jimenez
CREFITO 122314

Rua General Osrio, n 2567, Ciro Nardi, Cascavel - PR

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