Jonathan George

Patient Name 
 Unit # 
 Service/Location 
 Date 
 Status 
 Account # 
 Jonathan George 
 H42593902789 
 EMERGENCY ROOM A 
 27/07/2022
 DEP ER H00112738933 
 date of birth 
 Age 
 Sex MS Race Religion 
 Not Employed 
 xxx-xx-7234 
 30/06/1991 37 
 Address: 183 Johnson Isle
East Andrew, MA 30988 
 Language: ENG 
 XX 00000 
 County: MART 
 work Ph: 999-999-9999 
 OCCP: N 
 Home Phone: 552-344-9671 
 Cell Phone: 
 Country: USA 
 SUARAIOR EMPLOTER 
 Jonathan George 
 SS#: xxx-xx-7234 Rel/Pt: SELF 
 NOT EMPLOYED 
 Address: 
 WOT k. 999-999-9999 
 date of birth 30/06/1991 
 XX 00000 
 Occp: N 
 FCI99 
 Ins # 1 MCDPNDHCA 
 03831 
 Policy # 999999999 
 Auth Reqd-N Auth Date: 
 MEDICAID FL PENDING HCA 
 Insured Jonathan GeorgeJonathan George 
 Date 
 Work related accident? 
 11 ONSET OF SYMPTOMS ILLNESS 
 27/07/2022 
 Date injury/illness 
 Time: 
 Adm Priority: EM 
 Non-work related accident? NO 
 Senior Friend? 
 Date of accident: 
 Occr SpanCode: 
 From: 
 Thru: 
 Time: 
 Admission Comment: 
 Pt Valuables: 
 Spec Prg: 
 PHYSICIANS 
 Emergency Room Physician 
 Referring Physician 
 Dr Hannah Clark MD 
 SELF REFERRED 
 Other Physician 
 NO PRIMARY OR FAMILY PHYSICIAN 
 SELF REFERRED 
 Inflial 
 Date 
 Time Source 
 Rm/Bed 
 Arrival 
 Principal Admitting Diagnosis/Reason for Visit 
 Admitted By 
 25/10/2021 
 / 
 WALK IN 
 RT EYE SWELLING/HEADACHE, LT HAND WOUND DRAINAGE 
 1RSLCI6439 
 Rosewood General 
 EDF 
 Printed 05/30/23 0421 
 Acct# 
 Patient Name:Jonathan George 
 MRN:H42593902789 Encounter:H42593902789 Page 1 of 1

