Christopher Mcmahon

  
 Gulf Coast Surgical Center LLC 
 Christopher Mcmahon
 D.O.S: 27 January 2020 2:30:00 PM 
 ID / Visit: 48590 / 1 
 PATIENT INFO: 
 SEX: F 
 DATE OF BIRTH: 21 January 2003 
 AGE: 50 
 MAIN PHONE: 566-379-7497 
 ADDRESS: 034 Jimenez Valleys Apt. 894
Carolynmouth, ME 02615
 RESPONSIBLE PARTY: 
 BUGGAGE, 
 NADINE 
 A 
 034 Jimenez Valleys Apt. 894
Carolynmouth, ME 02615
 RSP SSN: 
 RSP OCC: TRMC 
 RSP PH: 623-567-5262 
 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 
 20 January 2017 
 1593 
 Witness 
 Date 
 Time 
 Signed
