Edwin Ali

  
 Gulf Coast Surgical Center LLC 
 Edwin Ali
 DOS: 2016/22/05 2:30:00 PM 
 ID / Visit: 48390 / 1 
 PATIENT INFO: 
 SEX: F 
 dob: 1989/09/07 
 AGE: 50 
 MAIN PHONE: 751-561-7710 
 ADDRESS: 123 Cody Fall
Ginabury, CT 52072
 RESPONSIBLE PARTY: 
 BUGGAGE, 
 NADINE 
 A 
 123 Cody Fall
Ginabury, CT 52072
 RSP SSN: 
 RSP OCC: TRMC 
 RSP PH: 608-872-7889 
 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 
 2016/20/01 
 1393 
 Witness 
 Date 
 Time 
 Signed
