Hospital Registration

-OP REGISTRATION

[This is a barely legible hospital form from 12/5/95.]

Name: MCPHERSON LISA

Prior Stay: 405-01-0149

Patient's Legal Address: [crossed out: "999 Homeless"] 901 Osceola Ave Apt 205

Tele 813 999-9999

Patient's Employer: AMC Publishing

Employer Address: Clearwater

Responsible Party: MCPHERSON LISA

Responsible Party's Address: 999 HOMELESS

Tele: 813 999-9999

Tele: 445 1269

Occurrence: 12-05-95

Notify in Emergency: JOHNSON JANIS

Home Tele: 813 XXX-XXXX

How Patient Arrived: AMB FRIEND

Complaint: Evaluation

Accident: Date: 12-05-05

Onset of Illness: Date: 12-05-95

Attending Physician: NILES D J