Sent 02/23/2026 12:10:21, Page - 11

Royal Columbian Hospital Emergency Registration Form
a
0 000 sera seat
MRN: RCOSOS0788
Name: HOLAND ,MARK THOMAS
DOB: 04/09/1978 46 (604) 822-2206 ARRIVAL: 19/05/2025 TIME: 08:15 LOCATION: RC.ER
SEX: M GPrademtluyi,Ghoghoade A SERVICE DATE: 19/05/2025 TIMm: 00:34
ARRIVAL MODE: Walking

PREFERRED WAME: REASON FOR VISIT:
MAIDEN NAME: LOW BP/CHEST PARIN/FAINTISH
ADDRESS: S11-318 AGNES ST

NEW WESTMINSTER, BC W3L 003 CHIEF COMPLAINT:
PRIMAR’ }394~3376 SECONDARY: Abcominal Fain~ looks well
PHN: 9128549738 INSURANCE : MSP
HEALTHCARENUM:
ACCIDENT: COMMENT:
DATE: TIME: PLACE:
PERSON TQ NOTIFY HOLAND, MELISSA WEXT OF KIN HOLAND,MELISSA
REL: Spouse PRIMARY: (604) 365-5726 REL: Spouse PRIMARY: (236) 513-5810
TRI DATE/TIME: 19/05/2025 08:25 OTAS: 3 ALERTS:
TEMP HR BP RR of Sat eos Glugeneter Lowation in Dept.
36.5 59 125/74 16 95 16/15 RCZONE2

Assessment of Chief Complaint:

HISTORY OF STOMACH ULCER, CHEST TIGHTNESS, NO NAUSEA, VOMITING, DIARRHEA FAINT LIKE FEELING WITH
LITTLE EXERTION. SYMPTOMS BEGAN LAST COUPLE OF WEEXS NO MELENA ZONE 2 INTAKE: TRIAGE NOTE VERITIED.
REPORTS LIGHTHEADEDNESS. DENIES MELENA, DI441NB#S3 OR ABDOMINAL PAIN

[ ] SPECIAL INDICATOR - DNA I ] SPECIAL INDICATOR - AVB

If applicable, apply CCI Stamp/Purple Det.

Accurate Patient Identity is Everyone's Responsibility
C1 Unable to verify patient information at the time of Registration.
C] Emergency Staff (1 Patient and/or Family member 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
] Verify patient information and send updates to Registration
via Order Management - ABU PTINFO Patient Information Edit.
Note:Changes cannot be corrected on the face sheet alone - information
mst oe updated in the system by submitting an ABU order.
[ ] Discharged Home - Unable to verify

CJ Unit Staff

RegacctaAdmr orm] pacan ada

PAGE 11/47 * RCVD AT 2/23/2026 12:10:26 PM [Pacific Standard Time] * SVR:FAXP21/3 * DNIS:9777 * CSID: * ANI:17783680130 * DURATION (mm-ss):21-27