Christopher Santiago

 
 The Gables Surgical Center 
 Christopher Santiago 
 DOS: 20-04-11 7:00:00 AM 
 ID /Visit: 117744/ 
 PATIENT INFO: 
 SEX: M 
 DOB: 03-01-19 
 AGE: 82 
 SSN: xxx-xx-xxxx 
 DRIVERS LICENSE: 
 OCCUPATION: 
 PH: 
 RESPONSIBLE PARTY: 
 Christopher Santiago 
 19254 NW 67 Place Miami Lakes, FL 33015 
 RSP SSN: xxx-xx-xxxx 
 RSP OCC: 
 PRIMARY INSURANCE: 
 SECONDARY INSURANCE: 
 Edersy Suarez Law Office LOP Christopher Santiago 
 14160 Palmetto Frontage Road. Suite #21 
 HIALEAH, FL 33016 
 POLICY: 86067124266 
 GROUP: Atty: Edersy Suarez 
 I 
 CERTIFY THAT I HAVE READ THE FOREGOING AND THAT I AM THE PATIENT, PARENT, LEGAL GUARDIAN OR AM DULY AUTHORIZED BY THE 
 PATIENT AS THE PATIENT'S GENERAL AGENT TO EXECUTE THE ABOVE AND ACCEPT ITS TERMS. 
 I 
 UNDERSTAND AND AGREE THAT, AT THE TIME THE PATIENT HAS MET THE GABLES SURGICAL CENTER'S MEDICAL CRITERIA TO LEAVE THE 
 FACILITY, 
 1 
 WILL HAVE A RESPONSIBLE ADULT PRESENT TO TAKE ME/PATIENT HOME. I RELEASE THE GABLES SURGICAL CENTER FROM ANY 
 RESPONSIBINITY EVENTS IN VIOLATION OF THIS AGREEMENT 
 June 
 19-10-13 
 06:21 
 Signed 
 Witness 
 Date 
 Time
