Sent 02/23/2026 12:10:21, Page - 7

a Royal Columbian Hospital Emergency Registration Form

TIL nee: eeegesea?
MRN: RCOSOS0788

Name: HOLAND ,MARK THOMAS

DOB: 04/09/1978 47 (604) 822-8206 ARRIVAL! 25/01/2026 TIME: 16:06 LOCATION: RC.ER
SEX: M GPrademtluyi,Ghoghoade A SERVICE DATE: 25/01/2026 TIMm:16:50
ARRIVAL MODE: Walking

PREFERRED WAME: REASON FOR VISIT:
MAIDEN NAME: EAR PAIN
ADDRESS: 311-318 AGNES sT

NEW WESTMINSTER, BC V3L 003 CHIEF COMPLAINT:

Primary: (296) 994-3976 Earache
PHN: 9128549738 INSURANCE : MSP
HEALTHCARENUM:
ACCIDENT: COMMENT:
DATE: TIME: PLACE :
PERSON TC NOTIFY HOLAND, MELISSA NEXT OF KIN HOLAMD, MELISSA
REL: Spouse PRIMARY: (604) 369-9726 RBs Spouse PRIMARY: (236) 313-5810
TRI DATE/TIME: 25/01/2026 Le6s41 OTAS: 4 ALERTS:
TEMP oR BR RR O2 Sat ecs Glucemeter Lodation in Dept.
37.4 76 126/83 16 98 18/15 ROZONE

Assessment of Chief Complaint:

Bilateral Rar Paim stating on Friday - progressively getting worse, Reporting HA, denies neck
stiffness. Denies dizziness or blurry vision. Denies CP, sob, cough or sore throat, denies jaw pain.
Localised pain to "ear drum’. Mild tinnitus (not new in/off for years) but worse today. Loud sounds
make ear pain worse. Denies N/V/D, denies diarrhea or concerns with GI/GU. Denies sick contacta.
Intake RN: Confirmed triage notes, pt refers bilat ear pain, left sright. Denies ear discharge,
refers headache, tock Ketorolac with some relief, refused pain meds at this time. Denies dizziness,
denies blurry vision, denies ILI symptoms, denies fever or chills at home. Refers intermittent
tinnitus, not present now. .....

( ] SPECIAL INDICATOR ~ DRA { ] SFRCTAL INDICATOR - AVE

tf applicable, apply Cct Stamp/Purple Det.

Accurate Patient Identity is Everyone's Responsibility
{ ] atient infermation at the time of Registration.
{[] Emergency Staff | [ ] Patient and/or family member sent to the Smergency
Registration Area ta verity information.
Discharged Home - Uneble to verify
Transfer to HC - Unable to verify, check off Unit Staff below
Verify patient information and send updates to Registration
via Order Management ~ ABU PTINEG Patient Information Edit.
Note:Changes cannot be corrected on the face sheet alone - information
must be updated in the system by submitting an ABU Order.
[1 Discharged Home - Unable to verity

| Unit Staff

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