Vanessa Bush

  
 Gulf Coast Surgical Center LLC 
 Vanessa Bush
 DOS: 2023/15/11 2:30:00 PM 
 ID / Visit: 48620 / 1 
 PATIENT INFO: 
 SEX: F 
 birth date: 2000/20/03 
 AGE: 50 
 MAIN PHONE: 943-986-7664 
 ADDRESS: 691 David Hill Suite 964
Johnsonberg, MD 28177
 RESPONSIBLE PARTY: 
 BUGGAGE, 
 NADINE 
 A 
 691 David Hill Suite 964
Johnsonberg, MD 28177
 RSP SSN: 
 RSP OCC: TRMC 
 RSP PH: 137-834-1799 
 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 
 2016/31/10 
 1623 
 Witness 
 Date 
 Time 
 Signed
