Justin Wallace

  
 Gulf Coast Surgical Center LLC 
 Justin Wallace
 DOS: 17/23/07 2:30:00 PM 
 ID / Visit: 48730 / 1 
 PATIENT INFO: 
 SEX: F 
 DATE OF BIRTH: 11/02/01 
 AGE: 50 
 MAIN PHONE: 293-921-3835 
 ADDRESS: PSC 1024, Box 8102
APO AE 71686
 RESPONSIBLE PARTY: 
 BUGGAGE, 
 NADINE 
 A 
 PSC 1024, Box 8102
APO AE 71686
 RSP SSN: 
 RSP OCC: TRMC 
 RSP PH: 860-623-2927 
 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 
 16/23/11 
 1733 
 Witness 
 Date 
 Time 
 Signed
