Veronica Bishop
 
 
 A 
 The Gables Surgical Center 
 11/2. 
 Patient Name: Veronica Bishop Date of 
 Procedure: 
 May 26, 2022 
 Diagnosis: M53.86, MUS.06, M47.26 
 ICD 9: M53.86, M48.06CPT: 22558 
 Procedure: 
 MU7.26. 
 Consent To Read: L45 interbody fusion with 
 bilateral pedical screws 
 Patient Address: asoo SW 48 St 
 City: Miami 
 State: FL 
 Zip: 33165 
 D.O.B: May 10, 1995 Age: 
 83. 
 Sex: M/F 
 Requires Transportation: ( ) Yes () No 
 Insurance Co. Name: 
 OMNi Atty: Edersy Suarez 
 Policy No: 
 Group No: 
 786-420-2893 
 Phone No: 
 Referral - Authorization No: 
 Worker's Comp ( ) Yes ( ) No Date of injury: 
 December 16, 2021 
 Claim No: 
 Adjuster: 
 leonard - No: Cannula 
 Instrumentation: 
 Type of 
 Anesthesia: General 
 Local 
 LOC/Sed 
 Regional 
 Choice 
 PRE - OP ANTIBIOTICS 
 PHYSICIAN SIGNATURE DR. JACObson & DR. Berti 
 The Gables Surgical Center 
 401 SW Lejeune Road, Suit 201 
 Miami FI 33134 
 Telephone: 305-447-0882 Fax 305-447-0213
