Sent 02/23/2026 12:10:21, Page - 2

a Royal Columbian Hospital Emergency Registration Form

CT IL nee: esse?

MRN: RCOSOS0788
Name: HOLAND ,MARK THOMAS
DOB: 04/09/1978 47 (604) 822-2206 ARRIVAL: 30/01/2026 TIME: 14:22 LOCATION: RC.ER

SEX: M GPrademtluyi,Ghoghoade A SERVICE DATE: 30/01/2026 TIMm:14:39
ARRIVAL MODE: Walking
PREFERRED MAME! REASON FOR VISIT:
MAIDEN NAME: LT EARACHE-WCR
ADDRESS: 311-319 AGNES st
NEW WESTMINSTER, BC V3L 003 CHIEF COMPLAINT:
Primary: (296) 994-3976 Ear Injury
PHN: 9128549738 INSURANCE : WCB
HEALTHCARENUM:
ACCIDENT: IND INJURED AT WORK COMMENT:
DATE: 30/01/2026 TIME: PLACE SAT WORK
PERSON TC NOTIFY HOLAND, MELISSA WEXT OF KIN HOLAND, MELISSA
REL: Spouse PRIMARY: (604) 369-9726 RBs Spouse PRIMARY: (236) 313-5810

TRI DATE/TIME: 30/01/2026 14:32 OTAS: 3 ALERTS:
TEMP oR BR RR O2 Sat ecs Glucemeter Lodation in Dept.
36.8 100 118/74 18 ino 18/15 ROZONE

Assessment of Chief Complaint:

PT REFORTS BILATERAL EAR PAIN WORSE ON LEFT? SHARP STABBING PAIN PT REPORTS 7ACQUSTIC TRAUMA FROM
WORKING BESIDE LOUD NOISY COMPUTER; ROUGHLY 19 HRS EXPOSURE DAILY PT REPORTS TINITTUS INTERMITTENTLY
AND BECOMING MORE PRONOUNCED. DENIES ANY BALANCE ISSUIS.

[ ] SPECIAL INDICATOR - DNA [ ] SPECIAL INDICATOR - AVE

If applicable, apply CCI Stamp/Purple Dot.

Accurate Patient Identity is Everyone's Responsibility
Unable to Verity patent datommatdion at the time of Regletoatilon.
Emergency Staf£ [ ] Batient and/or ramily menber sent to the Emergency
Registration Area to verify information.
Discharged Home - Unable to verify
Transfer to HLC - Unable to verify, check off Unit Staff below
VerLiy patient information and send updates to Registration
via Order Management - ABU PTINFO Patient Information Edit.
Note:Changes cannot be corrected on the face sheet alona - information
must be updated in the system by submitting an ABU Order.
L] Discharged Home - Unable to verify

CJ] Unit Staff

RegdcctAdm# ormlpaCanada

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