Diane Miller

  
 Gulf Coast Surgical Center LLC 
 Diane Miller
 DOS: 02/08/2019 2:30:00 PM 
 ID / Visit: 48470 / 1 
 PATIENT INFO: 
 SEX: F 
 birthdate: 19/03/2001 
 AGE: 50 
 MAIN PHONE: 784-850-3406 
 ADDRESS: 3140 Bartlett River
Port Chase, VT 57970
 RESPONSIBLE PARTY: 
 BUGGAGE, 
 NADINE 
 A 
 3140 Bartlett River
Port Chase, VT 57970
 RSP SSN: 
 RSP OCC: TRMC 
 RSP PH: 965-228-3580 
 I 
 UNDERSTAND AND AGREE THAT, AT THE TIME THE PATIENT HAS MET GULF COAST SURGICAL CENTER LLC's MEDICAL CRITERIA TO 
 LEAVE THE FACILITY, I WILL HAVE A RESPONSIBLE ADULT PRESENT TO TAKE ME/PATIENT HOME. I RELEASE GULF COAST SURGICAL 
 CENTER LLC FROM ANY RESPONSIBILITY FOR EVENTS IN VIOLATION OF THIS AGREEMENT. 
 Nadine Buggage Miniton 
 09/09/2019 
 1473 
 Witness 
 Date 
 Time 
 Signed
