Christina Evans

 
 MRN: 608698 
 Facility: NBMC 
 NorthBay Healthcare 
 Patient Discharge Instructions 
 Signature Page 
 Name: Miranda Stewart
 Current Date: 12-09-2016 00:16:37 
 MRN: 608652
 FIN: 010998052 
 I, FLORENTINO MEJIA-GALLEGOS, have received and verbalized understanding of the above 
 instructions, list of medications, and/or patient education material(s) and my questions have 
 been answered to my satisfaction. 
 Mantino My Gilbers 
 Patient 
 Date 
 Time 
 Family Member (Relationship) 
 Date 
 Time 
 A Damn 9867 
 16-10-2017
 0015 
 Provider Signature 
 Date 
 Time 
 00608698 
 12-11-2016 
 MEJIA-GALLEGOS, FLORENTIN 
 23-05-1985 26Y M 
 NBHS Emergency 0010998052
 . 
 000450012 
 . 
 Name: Miranda Stewart
 8 of 52 
 12-09-2016 00:16:38 AM 
 MRN: 608698 
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